you will take on the role of a psychology intern at a mental health facility working under the supervision of a licensed psychologist. I - Graduate Assignment Help\nyou will take on the role of a psychology intern at a mental health facility working under the supervision of a licensed psychologist. I\n8/14/2019 Psychiatry Online | DSM Library\nwith new information specifically addressed to individuals in the European Economic Area. As\ndescribed in the Priv acy Policy and T erms of Use, this website utiliz es cookies, including for the\npurpose of offering an optimal online experience and services tailored to y our preferences.\nwebsite, continuing the na vigation, or otherwise continuing to use the AP A’s websites, you confirm\nthat you understand and accept the terms of the Priv acy Policy and T erms of Use, including the\nutilization of cookies.\n  se ctio n s \nBack to table of contents Previous Chapter Next Chapter\n Full Access\nhttps://doi-org.pro xy-libr ary.ashford.edu/10.1176/appi.books.9781585624836.jb18\nIn tr o d u ctio n\nJo h n W . B arn hill, M .D .\nPer so na lit y is th e end uring pa tter n of b eh avio r a nd inner ex per ience. I t u nd erlies how we\nth ink , f eel , a nd a ct a nd f r a m es how we view ou rsel ves and t h e peo ple aro u nd u s. W hen we\nth ink o f wh o we are, we oft en th ink o f per sona lit y a s th e cent ra l d ef ining ch ara ct er ist ic.\nPsy ch iatr ist s and o th er m ent al h ea lt h pr act itio ner s spend co nsid erab le tim e th ink ing a b ou t\nper sona lit y a nd t h e wa ys in wh ich d ysf unct iona l per sona lit ies cause dist ress and\nd ysf unct ion in ind ivid uals and in th e peo ple aro u nd t h em . D iso rd er s of per sona lit y a re, in\nso me wa ys, a s co mplex a s hum an it y, it sel f f u ll o f id iosy ncr asies, h alf – a rticu la ted co nflict s,\nand u nk no wa ble co mplex ities. 8/14/2019 Psychiatry Online | DSM Library\nLik e m any o th er co mplex sy stem s, h owev er, per sona lit ies and per sona lit y d iso rd er s tend t o\nfa ll int o pa tter ns, a nd , f o r g ener atio ns, cl inicia ns and per sona lit y r esea rch ers fr o m a v a riet y\nof f iel ds have sea rch ed f o r a h oly g ra il : a no solo gica l sy stem t h at is b oth sim ple to u se and\nso ph istica ted eno ugh t o ca pture th e nu ances and pa ra d oxes of h um an per sona lit y.\nT ra d it io na lly , t h e fiel d o f psy chiatr y h as co ncept ualiz ed per sona lit y d iso rd er s ca teg orica lly ,\na s ref lect ing d ist inct cl inica l sy nd ro m es. I n ano th er pa ra d ig m , per so na lit y d iso rd er s are\nco ncept ualiz ed d im ensio nally , a s dysf unct iona l v a ria nt s of h um an per sona lit y t r a it s th at\nex ist o n a g ra d ient f r o m m ala d ap tiv e to no rm al. A s pa rt o f t h e D SM -5 d ev elopm ent\nprocess, a t ea m o f per sona lit y r es ea rch ers ex plored m ult ipl e wa ys to inco rpo ra te both\npa ra d ig m s, a nd a s a r esu lt cr ea ted a new hyb rid ca teg orica l- d im ensio nal m od el .\nAft er v ig oro u s deb ate am ong t ea m m em ber s, t h e D SM -5 t ex t incl udes th e tr a d it io na l\ncateg orica l m od el o f per sona lit y d iso rd er s as wel l a s th e new hyb rid ca teg orica l-\nd im ensio nal m od el . I t is th e tr a d it io na l ca teg orica l per spect ive th at is incl uded in th e m ain\nb od y o f t h e tex t, wh ile th e alt er na tiv e D SM -5 m od el f o r per sona lit y d iso rd er s is descr ibed\nin Sect ion III, “E mer ging M ea su res and M od el s.” This decisio n m ea ns th at t h e 10 D SM -I V\nper sona lit y d iso rd er s—a nd t h eir c rit er ia—r em ain essent iall y u nch ang ed. T he pr im ary\nsu bst ant ive ch ang e is th at a s pa rt o f t h e rem ova l o f t h e ax ia l sy stem , t h e per sona lit y\ndiso rd er s are no l o ng er l ist ed sepa ra tel y f r o m o th er D SM -5 d ia gno ses.\nTo b et ter u nd erstand t h e sim ilarit ies and d if fer ences of t h e two m od el s, it m ay b e usef ul t o\nex plore how th e two D SM -5 d ia gno stic system s reco mmend t h at a cl inicia n assess a pa tient\nwit h, f o r ex am ple, o b sessiv e-co mpu lsiv e per sona lit y d iso rd er ( O CP D). F ro m a ca teg orica l\nper spect ive, t h e ind ivid ual wo uld r eceiv e a d ia gno sis of O CP D wh en cer ta in criter ia wer e\nmet. F ir st , t h e cl inicia n sh ou ld id ent ify a per sist ent, d ysf unct iona l pa tter n of, f o r inst ance,\nper fect ionism a t t h e ex pense of f lex ibilit y. T he cl inicia n wo uld t h en ident ify a t l ea st f o u r o f\nsev en specif ic sympt om atic criter ia ( pr eo ccu patio n wit h l ist s, ina bil it y t o d el eg ate ta sk s,\nstubbornness, et c.) a nd sea rch f o r d iso rd er s th at m ight b e respo nsible fo r t h e sa me\nsy mpt om s (a nd t h at co uld l ea d t o eit her t h e co ding o f t h e oth er d ia gno sis onl y, su ch a s\nwh en sch izoph renia ca uses sympt om s ak in to t h ose fo u nd in OCP D, o r t h e co ding o f b oth\nd ia gno ses, su ch a s wh en th e per son also m eet s cr iter ia f o r a no th er per sona lit y d iso rd er ).\nT he new DSM -5 h yb rid m od el r es hapes th e 10 D SM -I V per sona lit y d iso rd er ca teg ories into\na r o st er o f six r ed efined ca teg orie s (a nt iso cial, a vo id ant , b ord er line, na rcissist ic, o b sessiv e-\ncompu lsiv e, a nd sch izoty pa l) . F or ea ch o f t h e six , t h e hyb rid m od el r eq uir es two 8/14/2019 Psychiatry Online | DSM Library\nassessm ents. T he fir st inv olv es a d et er mina tio n th at t h e ind ivid ual h as sig nifica nt\nimpairm ent in at l ea st t wo o f f o u r per sona lit y f u nct ioning a rea s: ident ity, sel f- d ir ect ion,\nem path y, a nd int imacy . F or ea ch o f t h e six per sona lit y d iso rd er s, t h ese persona lit y specif ics\ndif fer . F or ex am ple, t o q u alif y f o r O CP D, a n ind ivid ual m ight b e fo u nd t o h ave sig nifica nt\nimpairm ent f r o m a sense of sel f ex cessiv ely d er ived f r o m wo rk ( id ent ity) a nd f r o m r ig id ity\nand st ubbornness negativ ely a ffec ting r el atio nsh ips (int imacy ).\nT he new hyb rid m od el t h en req uir es an assessm ent o f per sona lit y t r a it s th at a re org aniz ed\nund er f iv e bro ad t r a it d om ains. A s sh own in 18- , t h ese tr a it s and t r a it d om ains exist o n a\nspect ru m ; fo r ex am ple, f o r o ne of t h e fiv e tr a it d om ains, a nt ag o nism l ies on one end o f t h e\nspect ru m a nd a g reea bleness on th e oth er . T hese fiv e bro ad t r a it d om ains are new to m any\npsy chiatr ist s, b u t t h ey h ave been rig oro u sl y st udied f o r sev eral d eca des wit hin aca dem ic\npsy cholo gy u nd er t h e ru bric of t h e Fiv e Fact or M od el , wh ose per sona lit y d im ensio ns\ninclude neu ro ticism , ex tr a ver sio n, a g reea bleness, co nscient iousness, a nd o penness. F or\nea ch o f t h ese persona lit y d im ensio ns, t h er e are cl ust er s of r el ated per sona lit y t r a it s.\nA ppl ied t o a pa rticu la r per son, t h e Fiv e Fact or M od el ca n assig n a per cent ile sco re fo r ea ch\ntr a it . F or ex am ple, t h e th eo ret ica l per son wit h O CP D m ight sco re in th e 95th per cent ile fo r\nco nscient iousness and in th e 5th per cent ile fo r o penness. D SM -5 a d apt ed t h ese persona lit y\ndim ensio ns and t r a it s in ord er t o m ore specif icall y f o cu s on psy chia tr ic diso rd er .\nAlt e rn ativ e D SM- 5 m od el: p ath olo g ic a l p ers o n ality tr ait d om ain s\nEn la rg e t a b le\nT went y-fiv e specif ic pa th olo gica l per sona lit y t r a it s are incl uded u nd er t h e um brel la o f t h ese\nfiv e neg ativ e tr a it d om ains. F or ea ch o f t h e per sona lit y d iso rd er s, D SM -5 r eq uir es th at t h e\nind ivid ual d em onst ra te m ost o f t h e ty pica l per sona lit y t r a it s. F or e x am ple, t h e pa tient wit h\nOCP D m ust d em onst ra te th e tr a it o f r ig id per fect ionism ( a n aspect o f t h e tr a it d om ain of\nco nscient iousness) a s wel l a s at l e a st t wo o f t h e fo llo wing t h ree tr a it s: per severatio n (a n\naspect o f neg ativ e affect ivity), int imacy a vo id ance (a n aspect o f d et ach ment ), a nd r est rict ed\naffect ivity ( a lso a n aspect o f d et ach m ent ).\nT he D SM -5 h yb rid m od el a lso specif ies th at specif ic tr a it s ca n be reco rd ed ev en if no t\nreco gniz ed a s pa rt o f a d ia gno sed per sona lit y d iso rd er ( e. g., h ost ilit y, a t r a it a sso ciated wit h\nth e tr a it d om ain of neg ativ e affec tiv ity, co uld b e list ed a lo ng sid e an y D SM -5 d ia gno sis and\nno t b e co nsid ered j u st a t r a it a sso ciated wit h, f o r inst ance, a nt iso cial per sona lit y d iso rd er ). 8/14/2019 Psychiatry Online | DSM Library\nBoth o f t h e D SM -5 m od el s have ad va nt ag es and d isa dva nt ag es. T he new DSM -5 h yb rid\nm od el m ight co ntrib ute to a m ore nu anced u nd erstand ing o f pa tient s, a nd it s appr oach\nta k es ad va nt ag e of d eca des’ wo rth o f per sona lit y r esea rch . I ts cu rrent co mplex ity is\nd au nt ing , h owev er, ev en to sea soned cl inicia ns, a nd t h e use of a ne w system wo uld\npo tent ially r ed uce th e usef ulness of ex ist ing r esea rch d ata wit hin psy ch iatr y .\nT he tr a d it io na l ca teg orica l pa ra d ig m h as been critiq ued f o r ex cessiv e co morb id ity a nd\nint ra d iso rd er h et er ogeneit y, a s wel l a s fo r t h e fa ct t h at o ne of t h e m ost co mmon per sona lit y\ndiso rd er d ia gno ses in th e pa st h as been “per sona lit y d iso rd er no t o th er wise specif ied,”\nwh ich is clarif ied o nl y m arg ina lly b y t h e D SM -5 u se of “o th er specif ied” and “u nspecif ied”\nper sona lit y d iso rd er s. O n th e oth er h and , t h e ca teg orica l a ppr oach is rel ativ ely\nst ra ig htfo rwa rd t o u se, is fa m ilia r f r o m D SM -I V, a nd f o llo ws th e ca teg orica l st ru ct ure used\nth ro u gh ou t t h e rest o f D SM -5 . I t is also t h e per sona lit y m od el incl uded in th e m ain bod y o f\nth e D SM -5 t ex t a nd , a s su ch , r em ains th e Am er ica n Psy ch iatr ic Asso cia tio n’s officia l\nperspect ive on per sona lit y d iso rd er s.\nSu ggeste d R ead in gs\nM acK inno n RA , M ich els R , B uck ley P J : T he Psy ch iatr ic Int erview in Clini cal P ra ct ice , 2 nd\nE dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing , 2 0 06\nM ich els R : Dia gno sing per sona lit y d iso rd er s . A m J Psy ch iatr y 16 9 (3): 2 4 1 – 24 3 , 2 0 12\nPubM ed I D : 2 24 0 710 9\nSh ed ler J, B eck A , F ona gy P , et a l: P er so na lit y d iso rd er s in DSM -5 . A m J Psy ch iatr y\n16 7 (9): 10 26 – 10 28 , 2 0 10 PubM ed I D : 2 0 826 8 53\nS ko d ol A E , B end er DS , O ld h am JM , et a l: P ro po sed ch ang es in per sona lit y a nd\nper sona lit y d iso rd er a ssessm ent a nd d ia gno sis fo r D SM -5 , pa rt I I : cl inica l a ppl icatio n .\nPer so na l D iso rd 2(1): 2 3 – 30 , 2 0 11 PubM ed I D : 2 24 48 68 8\nSko d ol A E , Cl ark L A , B end er DS , et a l: P ro po sed ch ang es in per sona lit y a nd per sona lit y\ndiso rd er a ssessm ent a nd d ia gno sis fo r D SM -5 , pa rt I : d escr iption and r a tio na le . P er so na l\nDiso rd 2(1): 4– 2 2 , 2 0 11 PubM ed I D : 2 24 48 68 7\nW est en D , S h ed ler J, B ra d ley B , D eF ife JA : A n em pirically d er ived t a x o no my f o r\nper sona lit y d ia gno sis : brid ging science and pr act ice in concept ualiz ing per sona lit y . A m J 8/14/2019 Psychiatry Online | DSM Library\nPsy ch iatr y 16 9 (3): 2 73 – 2 8 4 , 2 0 12 PubM ed I D : 2 219 35 34\nCase 1 8.1 P ers o n alit y C on ic ts\nL arry J. S ie ve r, M .D .\nLau ren C. Zalu da, B .A .\nFra zier A rch er wa s a 34 -y ea r-o ld sing le wh ite m an wh o ca ll ed a m ood a nd per sona lit y\ndiso rd er s resea rch pr ogra m b eca use an ex -fr iend h ad o nce said h e wa s “b ord er line, ” and\nM r. A rch er wa nted t o l ea rn m ore ab ou t h is per sona lit y co nflict s.\nDuring h is dia gno stic resea rch int erviews, M r. A rch er r epo rted r eg ula r, a lm ost d ail y\nsit uatio ns in wh ich h e wa s su re he wa s being l ied t o o r d eceiv ed. H e wa s pa rticu la rly wa ry\no f peo ple in lea der sh ip po sitions and peo ple wh o h ad st udied psy cholo gy a nd , t h er efore,\nh ad “t ra ining t o u nd erstand t h e hum an m ind ,” wh ich t h ey u sed t o m anipu la te peo ple.\nUnl ike th ose aro u nd h im , M r. A rc h er b el iev ed h e did no t “d rink t h e Kool- A id ” and wa s ab le\nt o d et ect m anipu la tio n and d eceit .\nMr. A rch er wa s ex tr em ely d et ail o rient ed a t wo rk , a nd h ad t r o u ble del eg ating a nd\nco mpleting t a sk s. N um er ou s em plo yer s had t o ld h im t h at h e fo cu sed ex cessiv ely o n ru les,\nlist s, a nd sm all d et ail s, a nd t h at h e need ed t o b e m ore fr iend ly . H e h ad h el d nu mer ou s jo b s\nover t h e yea rs, b u t h e wa s qu ick t o a d d , “I ’v e qu it a s oft en as I’v e been fir ed .” D uring t h e\nint erview, h e def end ed h is beh avio r, a sser ting t h at u nl ike m any peo ple, h e und erstood t h e\nva lu e of q u alit y o ver pr od u ct ivity. M r. A rch er’s wa riness had co ntrib uted t o h is “b ad\ntem per ” and em otio na l “u ps and d owns. ” H e so cia liz ed o nl y “su per ficia lly ” wit h a h and fu l\nof a cq uaint ances and co uld r eca ll t h e ex act m om ent s wh en previous “so -ca lled f r iend s and\nlo ver s” had b et ra yed h im . H e spent m ost o f h is tim e alo ne.\nM r. A rch er d enied a ny sig nifica nt h ist ory o f t r a u m a, a ny cu rrent o r pa st pr ob lem s wit h\nsubst ance use, a nd a ny h ist ory o f h ea d t r a u m a o r l o ss of co nscio usness. H e also d enied a ny\nh ist ory o f m ent al h ea lt h d ia gno sis or t r ea tm ent , b u t r epo rted t h at h e fel t h e m ight h ave a\nm ent al h ea lt h co nd itio n th at h ad no t y et b een dia gno sed .\nOn m ent al st atu s ex am ina tio n, M r. A rch er a ppea red wel l g ro om ed , co oper ativ e, a nd\no rient ed. H is speech v a ried ; at t im es he wo uld pa use th ou gh tfu lly pr ior t o a nswer ing\nqu est ions, ca using h is ra te of spee ch t o b e so mewh at sl ow. H is to ne also ch ang ed 8/14/2019 Psychiatry Online | DSM Library\nsignifica ntly wh en he discu ssed si tu atio ns th at h ad m ad e him a ng ry , a nd m any o f h is\nrespo nses were leng th y, d ig ressiv e, a nd v a g u e. H owev er, h e seem ed g ener ally co her ent a nd\nd id no t ev idence percept ual d iso rd er . H is affect wa s occa sionally ina ppr opr iate (e. g.,\nsm iling wh ile cr ying ) b u t g ener ally co nst rict ed. H e repo rted a pa th y a s to wh ether h e liv ed\nor d ied b u t d id no t r epo rt a ny a ct ive su icid al id ea tio n or h om icid al id ea tio n.\nNota b ly , M r. A rch er b eca me irrit ated a nd a rg u m ent ativ e wit h r esea rch st aff wh en he wa s\nto ld t h at a lt h ou gh h e co uld r eceiv e ver bal f eed back o n his int erviews, h e co uld no t r eceiv e a\nco py o f co mpleted q u est ionna ires and d ia gno stic to ols. H e co mment ed t h at h e wo uld\nd ocu ment in his per sona l r eco rd s th at r esea rch st aff wer e ref using h im t h e fo rm s.\nDia g n ose s\nPara no id per sona lit y d iso rd er\nO bsessiv e-co mpu lsiv e per sona lit y d iso rd er\nD is c u ssio n\nM r. A rch er d escr ibes a l o ng -st and ing , inf lex ible, d ysf unct iona l pa tter n of d ea ling wit h t h e\nwo rld . H e dem onst ra tes an end uring pa tter n of d ist ru st a nd su spicio usness. H e bel iev es\nth at o th er s are ex ploit ing o r d ecei ving h im ; d ou bts th e lo ya lt y o f f r iend s; bea rs gru dges;\nand r ecu rrent ly m ist ru st s th e fid elit y o f sex ual pa rtner s. T his clust er o f sy mpt om s qu alif ies\nhim f o r D SM -5 pa ra no id per sona lit y d iso rd er ( P PD ).\nA seco nd cl ust er o f per sona lit y t r a it s rel ates to M r. A rch er’s pr eo ccupa tio n wit h\nper fect ionism a nd co ntro l. H e is ex cessiv ely f o cu sed o n ru les, l ist s, a nd d et ail s. H e is\ninf lex ible and u na ble to d el eg ate. I n ad d it io n to P PD , h e has D SM -5 o b sessiv e-co mpu lsiv e\nper sona lit y d iso rd er ( O CP D).\nF or a ny o f t h e per sona lit y d iso rd er s, it is im porta nt t o ex clude th e ph ysio lo gica l ef fect s of a\nsu bst ance or a no th er m ed ica l co ndit io n; neit her o f t h ese appea rs lik ely in Mr. A rch er, wh o\ndenied a ll su bst ance ab u se, m ed ical il lness, a nd h ea d inj ury . F urth er more, h is pa tter ns of\nb eh avio r a ppea r t o b e end uring a nd no t r el ated t o eit her a m ajo r ch ang e in lif e\ncir cumstance or a no th er psy chiatr ic diso rd er .\nIt is unsu rpr ising t h at in ad dit io n to t h e PPD a nd O CP D d ia gno ses, M r. A rch er m eet s\npartia l cr iter ia f o r o th er per sona li t y d iso rd er s, incl uding sch izoty pa l, b ord er line, 8/14/2019 Psychiatry Online | DSM Library\nnarcissist ic, a nd a vo id ant per sona lit y d iso rd er s. P er so na lit y d iso rd er s are fr eq uent ly\nco morb id , a nd if a pa tient m eet s crit er ia f o r m ore th an one diso rd er , ea ch sh ou ld b e\nreco rd ed . P PD is especia lly u nl ikely t o b e an iso la ted d ia gno sis, in either cl inica l o r\nresea rch po pu la tio ns. P PD is oft e n co morb id wit h sch izoty pa l per sona lit y d iso rd er a nd /or\noth er sch izoph renia spect ru m d iso rd er s, a f ind ing a ttr ib uta b le to o ver la pping pa ra no ia-\nrel ated cr iter ia. I n M r. A rch er’s ca se, h is em otio na l inst ab il it y, a nx iet y, a ng er, a nd\na rro gance are sy mpt om s oft en fo u nd in a per sona lit y cl ust er t h at in cludes bord er line\nper sona lit y d iso rd er a nd na rcissis tic per sona lit y d iso rd er . B eca use of t h e rel ativ e\ninf req uency o f P PD a s an “iso la ted ” diso rd er , cu rrent r esea rch is point ing t o wa rd t h e\npo ssib ilit y t h at so me per sona lit y d iso rd er s, incl uding P PD , co uld b e co nso lid ated t o cr ea te\nm ore incl usiv e dia gno ses. P ara no ia wo uld t h en be viewed a s a specif ier o r m od if ier f o r\noth er d iso rd er s. T hat is no t t h e sit uatio n wit h D SM -5 , h owev er, a nd P PD sh ou ld co ntinu e\nto b e list ed a s a co morb id co nd itio n wh en criter ia a re m et.\nA seco nd int erest ing d ia gno stic issu e rel ated t o P PD is th e co ncer n a m ong so me cl inicia ns\nth at d ia gno sing P PD is ta nt am ou nt t o t r y ing t o id ent ify a n ea rly st ag e of sch izoph renia .\nTher e is genet ic, neu ro b io lo gica l, epid emiolo gica l, a nd sy mpt om atic evidence th at P PD ,\nlik e sch izoty pa l per sona lit y d iso rd er , is rel ated t o sch izoph renia a n d l ies on th e\nsch izoph renia spect ru m . H owev er, P PD is no t a pr ecu rso r t o sch izoph renia , a nd it s\nsy mpt om s are no t ind icativ e of t h e pr od ro m al ph ase of sch izoph renia . P ro d ro m al\nsch izoph renia is best ch ara ct er ized b y ea rly psy chotic sympt om s, incl uding d iso rg aniz ed\nth ou gh ts and b eh avio r, wh erea s th e th ou gh t pa tter ns in PPD a re gener ally m ore sim ilar t o\nth ose of d el usio nal d iso rd er a nd r el ated t h ou gh t d iso rd er s.\nBer man M E , F allo n A E , Co cca ro E F : The rel atio nsh ip bet ween persona lit y\npsy chopa th olo gy a nd a g gressiv e beh avio r in resea rch v o lu nt eer s . J Abno rm P sy ch ol\n10 7 (4): 6 51 – 6 58 , 19 98 P ubM ed I D : 9 8 30 252\nB er nst ein D , U sed a D , S iev er L : Para no id per sona lit y d iso rd er , in T he D SM -I V\nP er so na lit y D iso rd er s . E dit ed b y L iv esl ey WJ . N ew York , Gu ilfo rd , 19 95 , pp 4 5 – 57\nK end ler K S : D ia gno stic appr oach es to sch izoty pa l per sona lit y d iso rd er : a h ist orica l\nper spect ive . S ch izoph r B ull 11 (4) : 5 38 – 553 , 19 85 P ubM ed I D : 39 0937 7 8/14/2019 Psychiatry Online | DSM Library\nKend ler K S , N ea le M C , W alsh D : E va lu ating t h e spect ru m co ncept o f sch izoph renia in th e\nR osco mmon Fam ily S tu dy . A m J Psy ch iatr y 15 2 (5): 7 4 9 – 75 4 , 19 95 P ubM ed I D : 772 6 315\nSiev er LJ , D avis K L : The pa th oph ysio lo gy o f sch izoph renia d iso rd er s : per spect ives fr o m\nth e spect ru m . A m J Psy ch iatr y 16 1 (3): 39 8 – 413 , 2 0 04 P ubM ed I D : 14 9929 62\nSiev er LJ , K oenig sberg HW , H arv ey P , et a l: Co gnit ive and b ra in fu nct ion in sch izoty pa l\nper sona lit y d iso rd er . S ch izoph r R es 54 (1– 2 ): 15 7 – 16 7 , 2 0 02 P ubM ed I D : 118 539 90\nT hak er GK , R oss D E , Ca ssa dy SL , et a l: S acca dic eye m ovem ent a b no rm alit ies in rel ativ es\nof pa tient s wit h sch izoph renia . S ch izoph r R es 45 (3): 2 35 – 24 4 , 2 0 00 P ubM ed I D :\n110 424 41\nT rieb wasser J, Ch em erinsk i E , R ou sso s P , S iev er L : Para no id per sona lit y d iso rd er . J Per s\nDiso rd A ugu st 2 8 , 2 0 12 [ E pu b a h ea d o f pr int ] P ubM ed I D : 2 29 28 850\nZ im mer man M , Ch elm insk i I, Yo ung D : T he fr eq uency o f per sona lit y d iso rd er s in\npsy chiatr ic pa tient s . P sy ch iatr Cl in North A m 31 (3): 4 0 5 – 420 , 2 0 08 P ubM ed I D :\n18 638 643\nC ase 1 8.2 O ddly I s o la te d\nS alman Akh tar, M.D .\nGr zeg orz B uch alsk i wa s an 87-y ea r-o ld wh ite m an wh o wa s bro u gh t t o t h e psy chiatr ic\nem ergency r o om ( E R ) b y pa ra m ed ics aft er t h ey h ad b een called t o h is apa rtm ent b y\nneig hbors wh en th ey no ticed a n od d sm ell. A ppa rent ly , h is 90 -y ea r-o ld sist er h ad d ied\nso me days ea rlier a ft er a l eng th y i llness. M r. B uch alsk i h ad d el ayed r epo rting h er d ea th f o r\nsev eral r ea sons. H e had b eco me incr easing ly d iso rg aniz ed a s his sist er’s hea lt h h ad\nwo rsened , a nd h e wa s wo rried t h at h is la nd lo rd wo uld u se th e apa rtm ent ’s co nd itio n as a\npr etex t f o r ev ict ion. H e had t r ied t o cl ea n up, b u t h is attem pts co nsist ed m ainl y o f m oving\nit em s fr o m o ne place to a no th er . H e sa id h e wa s ab ou t t o ca ll f o r h el p wh en th e po lice and\npa ra m ed ics showed u p.\nIn th e ER , M r. B uch alsk i reco gniz ed t h at h is act io ns wer e od d a nd t h at h e sh ou ld h ave\nca lled f o r h el p so oner . A t t im es, h e beca me tea rfu l wh en discu ssing t h e sit uatio n and h is\nsist er’s dea th ; at o th er t im es, h e seem ed a lo of, spea king a b ou t t h es e in a ca lm , f a ct ual wa y. 8/14/2019 Psychiatry Online | DSM Library\nHe also wa nted t o cl arif y t h at h is apa rtm ent h ad ind eed b een a m ess bu t t h at m uch o f t h e\nappa rent m ess was act ually h is la rg e co llect ion of a rticl es on bio lu m inescence, a t o pic he\nhad b een resea rch ing f o r d eca des .\nA l icensed pl um ber , el ect ricia n, a nd l o ck sm ith, M r. B uch alsk i h ad wo rk ed u nt il a g e 65. H e\ndescr ibed h is la te sist er a s having b een alwa ys “a l it tle st ra ng e.” Sh e had nev er wo rk ed a nd\nh ad b een married o nce, b rief ly . A sid e fr o m t h e sev eral- m ont h m arria ge, sh e and M r.\nB uch alsk i h ad l iv ed in th e fa m ily’s two -b ed ro om M anh atta n apa rtm ent t h eir ent ire liv es.\nNeit her o f t h em h ad ev er seen a p sy ch iatr ist .\nWhen qu est ioned , M r. B uch alsk i st ated t h at h e had nev er h ad a r o m ant ic or sex ual\nrel atio nsh ip and h ad nev er h ad m any f r iend s or so cia l co ntact s ou tsid e his fa m ily. H e\nex plained t h at h e had b een poor a nd P olish a nd h ad h ad t o wo rk a ll t h e tim e. H e had t a k en\nnig ht cl asses to b et ter u nd erstand “t he st ra ng e wo rld we liv e in, ” an d h e sa id h is int ellect ual\nint erest s wer e wh at h e fo u nd m ost g ra tif ying . H e sa id h e had b een u pset a s he rea liz ed t h at\nh is sist er wa s dying , b u t h e wo uld ca ll it “nu mb” ra th er t h an depr essed . H e also d enied a ny\nh ist ory o f m anic or psy chotic sympt om s. A ft er a n hou r wit h t h e psy chiatr ic tr a inee, M r.\nB uch alsk i co nfided t h at h e hoped t h e m ed ica l sch ool m ight b e int erest ed in some of h is\npa per s aft er h is dea th . H e sa id h e b el iev ed t h at b io lu m inescent a nd g enet ic tech nolo gies\nwer e on th e ver ge of a b rea kth ro u gh t h at m ight a ll o w th e sk in of a n im als and t h en hum ans\nto g lo w in subtle co lo rs th at wo uld a ll o w peo ple to m ore dir ect ly r eco gniz e em otio ns. H e\nhad wr itten th e no tes fo r su ch t ec hno lo gy, b u t t h ey h ad g ro wn into a “wa y-to o-lo ng science\nf ict ion no vel wit h l o ts of f o otno te s. ”\nO n ex am ina tio n, M r. B uch alsk i wa s a t h in, el der ly m an dressed nea tly in kh ak is and\nb u tto n- down shirt. H e wa s m eticu lo u s and m uch pr efer red t o d iscu ss his int erest s in\nscience th an his own story . H e m ad e appr opr iate ey e co ntact a nd h ad a po lit e, pl ea sant\ndem eano r. H is speech wa s co her ent a nd g o al d ir ect ed. H is mood wa s “f ine, ” and h is affect\nwa s appr opr iate th ou gh per haps unu suall y ch eer fu l u nd er t h e cir cumstances. H e denied a ll\nsy mpt om s of psy chosis, d epr essio n, a nd m ania . A sid e fr o m h is co mm ent s ab ou t\nbio lu m inescence, h e sa id no th ing t h at so und ed d el usio nal. H e wa s co gnit ively int act , a nd\nh is insig ht a nd j u dgm ent wer e co nsid ered g ener all y g o od , a lt h ou gh h ist orica lly im paired in\nr eg ard t o h is del ay in calling t h e po lice ab ou t h is sist er.\nDia g n osis 8/14/2019 Psychiatry Online | DSM Library\nSch izoid per sona lit y d iso rd er\nM r. B uch alsk i’s alo of, t a cit urn, a n d a sex ual l if est yle cer ta inl y f it t h e dia gno stic criter ia f o r\nsch izoid per sona lit y d iso rd er ; h is ex plana tio n th at h e has been fr iend less beca use he is\nPolish a nd po or is a wea k r a tio na liz atio n fo r h is psy choso cia l d ef icit s. T he eccent ricit y o f\nh is int erest in bio lu m inescence, t h e ex ag ger ated est imatio n of t h e va lu e of h is “pa pers,” and\nth e fa ct t h at h e has liv ed pr etty m uch a ll h is lif e in th e fa m ily’s resid ence with h is sist er g iv e\nfu rth er ev idence of h is inwa rd pr eo ccu patio n and l a ck o f so cia l eng ag em ent . T he st rik ing\npo ver ty o f h is em otio na l r espo nse a t h is sist er’s pa ssing a wa y a nd h is fa il ure to m ak e any\nso rt o f f u ner al a rra ng em ent s are co nf irm ato ry o f a f la ttened a ff ect iv e lif e and wea k eg o\nskills. T he fa ct t h at h e is co gnit ively int act r u les ou t a g ra d u all y o ccu rring , d em ent ing\netio lo gy f o r h is wit hdra wa l a nd “c onf irm s” th e dia gno sis of sch izoid per sona lit y d iso rd er .\nSu ch a d ia gno sis has a l o ng h ist ory in psy chiatr y a nd psy choana ly sis. I n psy chiatr y , it s\norig ins go b ack t o E ugen Bleu ler , wh o co ined t h e ter m sc h iz oi d in 1908 t o d escr ibe a\nna tu ra l co mpo nent o f per sona lit y t h at pu lled o ne’ s attent ion to wa rd o ne’ s inner l if e and\nawa y f r o m t h e ex ter na l wo rld . H e l a b el ed a m orb id ex ag ger atio n of t h is tend ency a s\n“sch izoid per sona lit y.” Su ch ind ivid uals wer e descr ibed a s qu iet , su spicio us, a nd\n“co mfo rta b ly d u ll.” B leu ler ’s desc ript ion wa s el ab ora ted u po n over t h e nex t cent ury , a nd\nm any f ea tu res wer e ad ded t o it . T hese included so lit ary l if est yle, l o ve of b ooks, l a ck o f\nath let icism , t end ency t o wa rd a u tist ic th ink ing, po orly d ev eloped sex ualit y, a nd co ver t b u t\nint ense sensit ivity t o o th er s’ em otio na l r espo nses. T his la st f ea tu re, h owev er, g o t d ro pped\nfr o m t h e m ore recent po rtr a ya ls of sch izoid per sona lit y, incl uding t h e ones in DSM -I II a nd\nD SM -I V. D espit e th e reser va tio ns of m any inv estigato rs (e. g., O tto K er nb erg, Jo hn\nL iv esl ey, a nd m ysel f) , “l ack ing d esir e fo r cl ose rel atio nsh ips” beca me a pr im e cr iter ion fo r\nth e sch izoid d ia gno sis. A m ong o th er f a ct ors th at wer e em phasiz ed wer e asex ualit y,\nind iffer ence to pr aise or cr iticism , a nh edonia , a nd em otio na l co ld ness. T he hyper sensit ivity\ncr iter ion and t h e ost ensib le link t o sch izoph renia wer e assig ned, r e spect ively, t o t h e\nca teg ories of “a vo id ant ” and “sch izoty pa l” per sona lit y d iso rd er s.\nW ithin psy choana ly sis, t h e sch izoid co nd itio n wa s best d escr ibed b y W . R . D . F air bair n and\nH arry Gu ntrip. A cco rd ing t o t h em , int ense sensit ivity t o b oth l o ve and r ej ect ion and a\npr opensit y t o r ea dil y wit hdra w fr o m int erper sona l r el ated ness la y a t t h e co re of sch izoid\npa th olo gy. T he ind ivid ual t h us afflict ed o scil la ted b et ween wanting cl oseness and d rea ding 8/14/2019 Psychiatry Online | DSM Library\nit ; fea red t h e vig or o f h is or h er o wn need s and t h eir im pact o n oth er s; and wa s attr a ct ed t o\nlit er ary a nd a rtist ic act ivities beca use th ese were avenu es of sel f- ex pressio n wit hou t d ir ect\nhum an co ntact . S ch izoid per sona lit y ev olv ed f r o m o ne or m ore of t h e fo llo wing scena rio s:\n1) t a nt aliz ing r ef usa l b y ea rly ca re ta k er s th at a ro u sed f r ig htening a m ou nt s of em otio na l\nhung er; 2 ) ch ro nic parent al r ej ect ion, wh ich r esu lt ed in compliant a pa th y a nd l if el essness;\nand 3) su stained neg lect b y pa ren ts, wh ich l ed t o r et rea t int o t h e fa nt asy wo rld .\nT he ab sence of d ev elopm ental h ist ory a nd o f a ny d ata a b ou t M r. B uch alsk i’s ch ildh ood\nwea kens a psy chod yna mic und ersta nd ing o f M r. B uch alsk i’s sch izoid per sona lit y. H owev er,\ndev elopm ental h ist ory is no t a r eq uir ed cr iter ion fo r a d escr iptive dia gno sis; th is criter ion\nis pr im aril y u til iz ed b y psy chod yn am ica lly o rient ed psy chiatr ist s. A ll in all, t h e dia gno sis of\nsch izoid per sona lit y d iso rd er seem s rea sona ble fo r M r. B uch alsk i, a lt h ou gh so me m ight\narg u e in fa vo r o f a sch izoty pa l per sona lit y d iso rd er d ia gno sis giv en t h e od dit y o f h is\nint erest s. I f f u rth er ex plora tio n yiel ds inf orm atio n th at q u alif ies th is pa tient f o r b oth\nper sona lit y d iso rd er s, t h en both sh ou ld b e reco rd ed .\nIn reg ard t o o th er co morb id ities, t h e m ost l ik ely a ppea rs to b e hoard ing d iso rd er , a\nd ia gno sis new to D SM -5 . M r. B uch alsk i ind icates th at h e del ayed ca lling t h e po lice aft er h is\nsist er d ied b eca use he wa s wo rrie d t h at h is la nd lo rd wo uld u se th e co nd itio n of t h e\napa rtm ent a s a pr etex t f o r ev ict ion. H e descr ibes a l a rg e co llect ion of b io lu m inescence\npa per s, f o r ex am ple, a st atem ent t h at co uld m ea n a 2 -fo ot- ta ll st ack o f m anu scr ipts or a n\napa rtm ent cr am med t o t h e ceil ings wit h d eca des’ wo rth o f newspa pers, m ag azines, a nd\nscr ibbled no tes, sa ved b eca use of t h eir po tent ial u sef ulness. Cl arif ying t h e pr esence of t h is\n(o r a ny o th er ) co morb id co nd itio n wo uld b e cr ucia l t o t h e dev elopm ent o f a t r ea tm ent pl an\nth at t r ies to m ax im ize th e lik elih ood o f ind epend ent h appiness fo r t h is pa tient .\nAkh ta r S: S ch izoid per sona lit y d iso rd er : a sy nt hesis of d ev elopm ental, d yn am ic, a nd\nd escr iptive fea tu res . A m J Psy ch oth er 41 (4): 4 9 9 – 518 , 19 87 P ubM ed I D : 332 4773\nL iv esl ey WJ , W est M , T anney A : A h ist orica l co mment o n DSM -I II sch izoid a nd a vo id ant\nper sona lit y d iso rd er s . A m J Psy ch iatr y 14 2 (11 ): 134 4 – 1347 , 19 85 P ubM ed I D : 39 0448 9\nT rieb wasser J, Ch em erinsk i E , R ou sso s P , S iev er LJ : Sch izoid per sona lit y d iso rd er . J Per s\nDiso rd 2 6 (6): 9 19 – 926 , 2 0 12 PubM ed I D : 2 32 816 76 8/14/2019 Psychiatry Online | DSM Library\nCase 1 8.3 W orrie d a n d O ddly P re o cc u p ie d\nK ri st in Cad en head , M .D .\nHenr y, a 19 -y ea r-o ld co lleg e so ph om ore, wa s ref er red t o t h e st udent h ea lt h cent er b y a\nt ea ch ing a ssist ant wh o no ticed t h at h e appea red o d d, wo rried , a nd pr eo ccu pied a nd t h at\nh is la b no teb ook wa s fil led wit h b iz arrel y t h rea tening d ra wing s.\nHenr y a ppea red o n tim e fo r t h e psy ch iatr ic co nsu lt a tio n. A lt h ou gh su spicio us ab ou t t h e\nrea son fo r t h e ref er ra l, h e ex plained t h at h e gener all y “f ollo wed o rd er s” and wo uld d o wh at\nh e wa s ask ed . H e ag reed t h at h e had b een suspicio us of so me of h is cl assm ates, b el iev ing\nth ey wer e und ermining h is ab il it ies. H e sa id t h ey wer e tel ling h is instru ct ors th at h e wa s “a\nweir d g u y” and t h at t h ey d id no t wa nt h im a s a l a b pa rtner . T he ref er ra l t o t h e psy chiatr ist\nwa s, h e sa id, co nfirm atio n of h is per cept ion.\nHenr y d escr ibed h ow he had seen two st udent s “f lip a co in” over wh ether h e wa s gay o r\nst ra ig ht. Co ins, h e asser ted , co uld o ft en pred ict t h e fu tu re. H e had o nce flipped a co in and\n“h eads” had pr ed ict ed h is moth er ’s illness. H e bel iev ed h is th ou gh ts oft en came tr u e.\nH enr y h ad t r a nsf erred t o t h is ou t- o f- to wn univ ersit y a ft er a n init ial y ea r a t h is lo ca l\nco mmunit y co lleg e. T he tr a nsf er wa s his pa rent s’ id ea , h e sa id, a nd wa s pa rt o f t h eir a g end a\nto g et h im t o b e lik e ev eryo ne else and g o t o pa rties and h ang o u t w ith g ir ls. H e sa id a ll su ch\nbeh avio r wa s a wa ste of t im e. A lt h ou gh t h ey h ad t r ied t o pu sh h im int o m oving int o t h e\ndorm s, h e had r ef used , a nd inst ead l iv ed b y h im sel f in an off – ca mpu s apa rtm ent .\nWith H enr y’s per missio n, h is moth er wa s ca ll ed f o r co lla ter al inf orm atio n. S h e sa id H enr y\nhad b een qu iet , sh y, a nd r eser ved since childh ood . H e had nev er h ad cl ose fr iend s, h ad\nnev er d ated , a nd h ad d enied wa nting t o h ave fr iend s. H e ack no wled ged f eel ing d epr essed\nand a nx ious at t im es, b u t t h ese feel ing s did no t im prove wh en he wa s aro u nd o th er peo ple.\nHe wa s tea sed b y o th er k id s and wo uld co me hom e upset . H is moth er cr ied wh ile\nex plaining t h at sh e alwa ys fel t b ad f o r h im b eca use he nev er r ea ll y “f it in, ” and t h at sh e and\nh er h usb and h ad t r ied t o co ach h im f o r y ea rs wit hou t su ccess. S h e wo ndered h ow a per son\nco uld f u nct ion wit hou t a ny so cia l l if e.\nSh e ad ded t h at g h ost s, t el epa th y, a nd wit chcraft h ad f a scina ted H enr y since ju nio r h ig h\nsch ool. H e had l o ng t h ou gh t t h at h e co uld ch ang e th e ou tco me of ev ent s lik e ea rth qu ak es\nand h urrica nes by t h ink ing a b ou t t h em . H e had co nsist ently d enied su bst ance ab u se, a nd 8/14/2019 Psychiatry Online | DSM Library\ntwo d ru g scr eens had b een negativ e in th e pr ior 2 y ea rs. S h e m ent ioned t h at h er\ngra nd fa th er h ad d ied in an “insa ne asy lu m ” m any y ea rs bef ore H enr y wa s born, b u t sh e did\nno t k no w his dia gno sis.\nOn ex am ina tio n, H enr y wa s ta ll, t h in, a nd d ressed in jea ns and a T -sh irt. H e wa s aler t a nd\nwa ry a nd , a lt h ou gh no nspo ntaneo us, h e answer ed q u est ions dir ect ly . H e denied f eel ing\ndepr essed o r co nfused . H enr y d en ied h aving a ny su icid al t h ou gh ts, pl ans, o r a ttem pts. H e\ndenied h aving a ny a u dit ory o r v is ual h allu cina tio ns, pa nic atta ck s, o b sessio ns,\ncompu lsio ns, o r ph ob ia s. H is int ellect ual sk ills seem ed a b ove aver ag e, a nd h is Mini- Ment al\nS ta te Exam ina tio n sco re wa s 30 o u t o f 30 .\nSch izoty pa l per sona lit y d iso rd er\nP ara no id per sona lit y d iso rd er\nH enr y pr esent s wit h a pa tter n of so cia l a nd int erper sona l d ef icit s acco mpa nied b y\neccent ricit ies and co gnit ive dist ortio ns. T hese include del usio nal- lik e sy mpt om s (m ag ica l\nth ink ing, su spicio usness, id ea s of r ef er ence, g ra nd iosit y), eccent ric int erest s, ev idence of\nwit hdra wa l ( few fr iend s, a vo id anc e of so cia l co ntact ), a nd r est rict ed a ffect ( em otio na l\ncold ness) . T her efore, H enr y a ppe ars to m eet cr iter ia f o r D SM -5 sch izoty pa l per sona lit y\ndiso rd er .\nHenr y a lso su spect s th at o th er s are und ermining h im , r ea ds hid den mea ning int o b enig n\nact ivities, b ea rs gru dges, a nd is over ly sensit ive to per ceiv ed a tta ck s on his ch ara ct er . I n\na d dit io n to sch izoty pa l per sona lit y d iso rd er , h e m eet s cr iter ia f o r pa ra no id per sona lit y\ndiso rd er . I f a n ind ivid ual m eet s cr iter ia f o r t wo per sona lit y d iso rd er s—a s is oft en th e ca se—\nboth sh ou ld b e reco rd ed .\nHenr y, h owev er, is onl y 19 y ea rs old , a nd a per sona lit y d iso rd er d ia gno sis shou ld b e m ad e\nonl y a ft er ex ploring o th er d ia gno ses th at co uld pr od u ce sim ilar sy mpt om s. F or ex am ple,\nHenr y’s def icit s in socia l co mmun ica tio n and int eract io n co uld b e co nsist ent wit h a\nd ia gno sis of a u tism spect ru m d iso rd er ( A SD ) wit hou t int ellect ual im pairm ent . I t is po ssib le\nt h at h e had u nr epo rted sy mpt om s bey ond “sh yness” in th e ea rly d ev elopm ental per iod, 8/14/2019 Psychiatry Online | DSM Library\nand , a s wa s repo rted a b ou t H enr y, ch ildren wit h A SD co mmonl y u nd ergo sch ooly a rd\ntea sing . H e and h is moth er d o no t, h owev er, r epo rt t h e so rts of r est rict ed, r epet itiv e\npa tter ns of b eh avio r, int erest s, o r a ct ivities th at a re also a h all m ark o f A SD . W ithou t t h ese,\nH enr y wo uld no t b e dia gno sed o n t h e au tism spect ru m .\nHenr y a lso m ay h ave a psy chiatr ic diso rd er t h at d ev elops in yo u ng a d u lt h ood , a nd h e is at\nth e pea k a g e fo r t h e onset o f d epr essiv e, b ipo la r, a nd a nx iet y d iso rd er s. A ny o f t h ese can\nex acer bate basel ine persona lit y t r a it s and m ak e th em a ppea r t o b e diso rd er s, b u t H enr y\ndoes not a ppea r t o h ave sig nifica nt d epr essiv e, m anic, o r a nx iet y sy mpt om s.\nM ore lik ely in th is case wo uld b e a d ia gno sis on th e sch izoph renia spect ru m . F or H enr y t o\nh ave an act ual sch izoph renia d ia gno sis, h owev er, h e wo uld need t o h ave two o r m ore of t h e\nfo llo wing f iv e cr iter ia: d el usio ns, h allu cina tio ns, d iso rg aniz ed speech , g ro ssl y d iso rg aniz ed\nor ca ta to nic beh avio r, a nd neg ativ e sy mpt om s. B eca use he denies hallu cina tio ns and\nappea rs to b e lo gica l a nd no t t o h ave eit her o d d b eh avio r o r neg ativ e sy mpt om s, h e does\nno t h ave sch izoph renia . I nst ead, h e m ay h ave del usio ns—a nd it wo uld b e usef ul t o cl arif y\nth e ex tent t o wh ich h e has fix ed , f a lse bel ief s ab ou t pr ed ict ing a nd a ffect ing t h e fu tu re—b ut\nh is bel ief s seem m ore biz arre th an th ose ty pica ll y seen in del usio nal d iso rd er .\nAlt h ou gh H enr y cu rrent ly m ay b est f it t h e two per sona lit y d iso rd er d ia gno ses list ed a b ove,\nh e m ay g o o n to d ev elop a m ore ex plicit ly psy chotic diso rd er . P sy ch iatr ic clinicia ns and\nresea rch ers are pa rticu la rly int erest ed in dist ing uish ing ind ivid uals wh o pr esent a s unu sual\na s teena ger s and a re lik ely t o g o o n to d ev elop a m ore disa bling sch izoph renia f r o m t h ose\nwh o pr esent sim ilarly b u t wil l no t g o o n to d ev elop a m ajo r psy chiatr ic diso rd er . A lt h ou gh\nth e cu rrent a b il it y t o pr ed ict sch izoph renia is no t r o b u st , ea rly int erv ent ion co uld\nsu bst ant ially r ed uce th e psy cholo gica l su ffer ing a nd t h e lo ng -ter m f u nct iona l\nconseq uences. T o t h at end , D SM -5 S ect ion III incl udes attenu ated psy chosis synd ro m e as\no ne of t h e co nd itio ns fo r f u rth er s tu dy. A ttenu ated psy chosis synd ro m e fo cu ses on\nsu bsy nd ro m al sy mpt om s, incl uding im paired insig ht a nd f u nct ionalit y, in an effo rt t o\ncl arif y wh ich pa tient s are in th e pro cess of a d ecl ine into sch izoph renia a nd wh ich pa tient s\nare dem onst ra ting t h e beg inning s of a m ore cr yst alliz ed per sona lit y d iso rd er .\nAdding to n J, Co rnb la tt B A , Ca denh ead KS , et a l: A t cl inica l h ig h r isk f o r psy chosis:\nou tco me fo r no nco nverter s . A m J Psy ch iatr y 16 8 (8 ): 8 0 0 – 80 5 , 2 0 11 PubM ed I D : 8/14/2019 Psychiatry Online | DSM Library\n214 98 46 2\nA hm ed AO , Gr een BA , Go od ru m N M , et a l: D oes a l a tent cl ass und erlie sch izoty pa l\nper sona lit y d iso rd er ? Im plica tio ns fo r sch izoph renia . J Abno rm P sy ch ol 12 2 (2): 4 75 – 4 9 1 ,\n20 13 PubM ed I D : 2 37 135 03\nFish er JE , H eller W , M iller GA : N eu ro psy cholo gica l d if fer ent iatio n of a d apt ive cr ea tiv ity\nand sch izoty pa l co gnit ion . P er s Ind ivid D if 54 (1): 7 0 – 75 , 2 0 13 PubM ed I D : 2 310 974 9\nC ase 1 8.4 U nfa ir n ess\nCh arle s L. S co tt, M .D .\nIk e Cr ock er wa s a 32 -y ea r-o ld m an ref er red f o r a m ent al h ea lt h ev alu atio n by t h e hum an\nreso urces depa rtm ent o f a l a rg e co nst ru ct io n bu siness th at h ad b ee n his em ployer f o r 2\nweek s. A t h is init ial j o b int erview, M r. Cr ock er pr esent ed a s ver y m otiv ated a nd pr ovid ed\ntwo ca rpent ry sch ool cer tif ica tio ns th at ind icated a h ig h l ev el o f sk ill a nd t r a ining . S ince his\nem ploym ent b eg an, h is su per viso rs had no ted f r eq uent a rg u m ent s, a b sent eeism , po or\nwo rk m ansh ip, a nd m ult ipl e er ro rs th at m ight h ave been dang erou s. W hen confro nt ed , h e\nwa s repo rted ly d ism issiv e, ind icating t h at t h e pr ob lem wa s “ch eap wo od ” and “b ad\nm ana gem ent ” and a d ded t h at if so meo ne go t h urt, “it ’s beca use of t h eir o wn stupid ity.”\nW hen th e hea d o f h um an reso urc es met wit h h im t o d iscu ss ter min atio n, M r. Cr ock er\nqu ick ly po int ed o u t t h at h e had b oth a ttent ion- def icit /hyper act ivity d iso rd er ( A D H D) a nd\nb ipo la r d iso rd er . H e sa id t h at if n ot g ra nt ed a n acco mmod atio n und er t h e Am er ica ns wit h\nDisa bil it ies Act , h e wo uld su e. H e d em and ed a psy chiatr ic evalu atio n.\nDuring t h e m ent al h ea lt h ev alu atio n, M r. Cr ock er f o cu sed o n unf air ness at t h e co mpa ny\nand o n how he wa s “a h el l o f a b et ter ca rpent er t h an any one th er e co uld ev er b e. ” H e\nclaim ed t h at h is two m arria ges had end ed b eca use of j ea lo u sy . H e sa id t h at h is wiv es wer e\n“alwa ys th ink ing I wa s wit h o th er wo men, ” wh ich is wh y “t hey b oth l ied t o j u dges and g o t\nrest ra ining o rd er s sa ying I ’d h it t h em .” A s “pa yb ack f o r t h e ja il t im e,” he ref used t o pa y\nchild su ppo rt f o r h is two ch ildren. H e had no int erest in seeing eit her o f h is two b oys\nb eca use th ey wer e “little lia rs” lik e th eir m oth er s.\nM r. Cr ock er sa id h e “m ust h ave been smart” beca use he had b een ab le to m ak e Cs in sch ool\nd espit e sh owing u p onl y h alf t h e tim e. H e spent t im e in ju venil e hall a t a g e 14 f o r st ea ling 8/14/2019 Psychiatry Online | DSM Library\n“kid st uff, l ik e tennis shoes and wa llet s th at wer e pr act ica lly em pty.” H e lef t sch ool a t a g e 15\naft er b eing “f ra m ed f o r st ea ling a ca r” by h is pr incipa l. M r. Cr ock er po int ed o u t t h ese\nhist orica l f a ct s as ev idence th at h e wa s ab le to o ver co me inj ust ice and a d ver sit y.\nIn reg ard t o su bst ance use, M r. C ro ck er sa id h e sm oked m arij uana a s a t eena ger a nd\nst arted d rink ing a lco hol o n a “r eg ula r b asis” aft er h e fir st g o t m arried a t a g e 22. H e denied\nth at u se of eit her su bst ance was a pr ob lem .\nMr. Cr ock er co ncl uded t h e int erview by d em and ing a no te fr o m t h e ex am iner t h at h e had\n“b ipo la r” and “A DH D.” H e sa id t h at h e wa s “b ipo la r” beca use he had “u ps and d owns” and\ng o t “m ad r ea l f a st .” M r. Cr ock er d enied o th er sy mpt om s of m ania . H e sa id h e go t d own\nwh en disa ppo inted, b u t h e had “a sh ort m em ory ” and “co uld g et o u t o f a f u nk pr etty q u ick .”\nM r. Cr ock er r epo rted no d if ficu lt ies in his sleep, m ood , o r a ppet ite. H e lea rned a b ou t\nA D H D b eca use “both o f m y b oys go t it .” H e co ncl uded t h e int erview with a r eq uest f o r\nm ed ica tio ns, a d ding t h at t h e onl y o nes th at wo rk ed wer e st im ula n ts (“a ny o f t h em ”) a nd a\nspecif ic sh ort- a ct ing b enz od ia zepine.\nO n m ent al st atu s ex am ina tio n, M r. Cr ock er wa s a ca su all y d ressed wh ite m an wh o m ad e\nrea sona ble ey e co ntact a nd wa s w ithou t a b no rm al m ovem ent s. H is speech wa s co her ent ,\ngo al d ir ect ed, a nd o f no rm al r a te. T her e wa s no ev idence of a ny t h ou gh t d iso rd er o r\nh allu cina tio ns. H e wa s pr eo ccu pied wit h b la m ing o th er s, b u t t h ese co mment s appea red t o\nr epr esent o ver va lu ed id ea s ra th er t h an del usio ns. H e wa s co gnit ively int act . H is insig ht\nint o h is sit uatio n wa s po or.\nT he hea d o f h um an reso urces did a b ack gro u nd ch eck d u ring t h e co urse of t h e psy chiatr ic\nev alu atio n. P hone calls rev ea led t h at M r. Cr ock er h ad b een expel led f r o m t wo ca rpent ry\ntr a ining pr ogra m s and t h at b oth h is gra d u atio n cer tif ica tes had b een fa lsif ied . H e had b een\nfir ed f r o m h is jo b a t o ne lo ca l co nst ru ct io n co mpa ny a ft er a f ist fig ht wit h h is su per viso r a nd\nfr o m a no th er j o b a ft er a b ru pt ly l e a ving a j o b sit e. A q u ick r ev iew of t h eir r eco rd s ind icated\nth at h e had pr ovid ed t h em wit h t h e sa me fa lse docu ment atio n.\nDia g n osis\nA nt iso cial per sona lit y d iso rd er\nD is c u ssio n 8/14/2019 Psychiatry Online | DSM Library\nMr. Cr ock er h as a per va siv e pa tter n of d isr egard f o r a nd v io la tio n of t h e rig hts of o th er s, a s\nind icated b y m any d if fer ent a ct io ns. H e has been arrest ed t wice fo r d om est ic vio lence—\no nce each f r o m t wo sepa ra te m arr ia ges—a nd h as spent t im e in ja il . M r. Cr ock er h as\nfa lsif ied h is carpent ry cr ed ent ials a nd pr ovid es am ple ev idence of r epea ted f ig hts and\nir rit ab il it y, b oth a t wo rk a nd wit hin his rel atio nsh ips. H e dem onst ra tes lit tle or no r eg ard\nfo r h ow his act io ns affect t h e sa fet y o f h is co wo rk er s. H e ref uses to see his yo u ng so ns or\npa y ch ild su ppo rt, b eca use th ey a re “little lia rs. ” H e ex hib its no r em orse fo r h ow his act io ns\nneg ativ ely a ffect h is fa m ily, co wo rk er s, o r em ployer s. H e ro u tinel y q u it s jo b s and f a il s to\npl an ah ea d f o r h is nex t em ploym ent . H e m eet s all sev en of t h e sy mpt om atic criter ia f o r\nD SM -5 a nt iso cial per sona lit y d iso rd er ( A PD ).\nT he dia gno sis of A PD ca nno t b e m ad e unt il a g e 18 , b u t it d oes req uir e ev idence fo r co nd uct\ndiso rd er b ef ore ag e 15 . M r. Cr ock er’s hist ory ind icates a h ist ory o f t r u ancy , a d ju dica tio n fo r\nth ef t a t a g e 14 , a nd ex pu lsio n fr o m sch ool a t a g e 15 f o r ca r t h ef t.\nA t t h e end o f t h e ev alu atio n, M r. Cr ock er r eq uest s two po tent iall y a d dict ive m ed ica tio ns.\nHe sm oked m arij uana in hig h sch ool a nd m ay h ave beg un to d rink a lco hol h ea vil y in his\n20 s. A lt h ou gh it m ight b e dif ficu lt t o el icit a n honest a cco unt o f h is su bst ance use, M r.\nCr ock er m ay ind eed h ave a co morb id su bst ance use diso rd er . S u ch a d ia gno sis would no t\naffect h is dia gno sis of A PD , h owe ver , b eca use his ant iso cial b eh avio r pr ed ates his repo rted\nu se of su bst ances. I n ad dit io n, h is ant iso cial a ttit udes and b eh avio rs are m anif est in\nm ult ipl e set ting s and a re no t sim ply a r esu lt o f h is su bst ance ab u se (e. g., st ea ling t o pa y f o r\nh is dru gs) .\nM r. Cr ock er’s cl aim t h at h e has AD H D wo uld r eq uir e ev idence th at h e had so me\nhyper act ive- im pulsiv e or ina ttent ive sy mpt om s th at ca used im pairm ent b ef ore ag e 12\nyea rs. A lt h ou gh A D H D co uld b e a co morb id co nd itio n and co uld a cco unt f o r so me of h is\nim pulsiv ity, it wo uld no t a cco unt f o r h is wid e-ra ng ing a nt iso cial b eh avio r.\nT he APD d ia gno sis also r eq uir es th at t h e beh avio r no t o ccu r o nl y d u ring t h e co urse of\nb ipo la r d iso rd er o r sch izoph renia . A lt h ou gh M r. Cr ock er st ates th at h e has bipo la r\nd iso rd er , h e pr ovid es no ev idence th at h e has ev er b een manic (o r sch izoph renic) .\nMr. Cr ock er’s int erper sona l st yle is mark ed b y ca ll o u s disr egard f o r t h e feel ing s of o th er s\nand a n arro gant sel f- a ppr aisa l. S u ch q u alit ies can be fo u nd in oth er per sona lit y d iso rd er s,\nsu ch a s na rcissist ic per sona lit y d iso rd er , b u t t h ey a re also co mmon in APD . A lt h ou gh 8/14/2019 Psychiatry Online | DSM Library\ncomorb id ity is no t u nco mmon, in div id uals wit h na rcissist ic per sona lit y d iso rd er d o no t\nexhib it t h e sa me lev els of im pulsi vit y, a g gressio n, a nd d eceit a s are pr esent in APD .\nInd ivid uals wit h h ist rio nic personalit y d iso rd er o r b ord er line persona lit y d iso rd er m ay b e\nm anipu la tiv e or im pulsiv e, b u t t h eir b eh avio rs are no t ch ara ct er ist ica lly a nt iso cial.\nI nd ivid uals wit h pa ra no id per sona lit y d iso rd er m ay d em onst ra te ant iso cial b eh avio rs, b u t\nth eir a ct io ns tend t o st em f r o m a pa ra no id d esir e fo r r ev eng e ra th er t h an a d esir e fo r\nper sona l g ain. F ina lly , peo ple wit h int ermittent ex plosiv e diso rd er a lso g et int o f ig hts, b u t\nth ey l a ck t h e m any ex ploit iv e tr a it s th at a re a per va siv e pa rt o f A PD .\nEdwa rd s D W , S co tt CL , Ya rv is R M , et a l: I m pu lsiv eness, im pulsiv e ag gress ion, per sona lit y\ndiso rd er , a nd spo usa l v io lence . Vio lence Vict 18 (1): 3– 14 , 2 0 03 PubM ed I D : 12 7336 16\nWyg ant D B , S el lb om M : Viewing psy chopa th y f r o m t h e per spect ive of t h e Per so na lit y\nPsy ch opa th olo gy F iv e m od el : im plica tio ns fo r D SM -5 . J Per s D iso rd 2 6 (5): 7 17 – 72 6 , 2 0 12\nPubM ed I D : 2 30 1334 0\nCase 1 8.5 F ra g il e a n d A ngry\nFran k Y eo man s, M .D ., P h.D .\nOtto K ern berg , M .D .\nJu anit a D el gad o, a sing le, u nem plo yed H ispa nic woman, so ugh t t h er apy a t a g e 33 fo r\ntr ea tm ent o f d epr essed m ood , ch ro nic suicid al t h ou gh ts, so cia l iso la tio n, a nd po or per sona l\nhyg iene. S h e had spent t h e pr ior 6 m ont hs iso la ted in her a pa rtm ent , l y ing in bed , ea ting\nju nk f o od , wa tch ing t el ev isio n, a nd d oing m ore onl ine shopping t h an sh e co uld a ffo rd .\nM ult ipl e tr ea tm ent s had y iel ded l it tle ef fect .\nMs. D el gad o wa s th e m iddle of t h ree children in an upper -m iddle- class im migra nt f a m ily in\nwh ich t h e fa th er r epo rted ly v a lu ed pr ofessio nal a ch iev em ent o ver a ll el se. S h e fel t iso la ted\nth ro u gh ou t h er sch ool y ea rs and ex per ienced r ecu rrent per iods of d epr essed m ood . W ithin\nher f a m ily, sh e wa s kno wn fo r a ng ry o u tb u rst s. S h e had d one wel l a ca dem ically in hig h\nsch ool b u t d ro pped o u t o f co lleg e b eca use of f r u st ra tio ns wit h a r o om mate and a pr ofesso r.\nS h e attem pted a ser ies of int ernsh ips and ent ry -lev el j o b s wit h t h e ex pect atio n th at sh e\nwo uld r et urn to co lleg e, b u t sh e kept q u it ting b eca use “bosses are id iots. T hey co me acr oss 8/14/2019 Psychiatry Online | DSM Library\nas grea t a nd t h ey a ll t u rn ou t t o b e twist ed.” These “tra u m as” alwa ys lef t h er f eel ing t er rib le\na b ou t h er sel f ( “I ca n’t ev en succeed a s a cl er k?”) a nd a ng ry a t h er b osses (“I co uld r u n th e\npl ace and pr ob ab ly wil l”) . S h e had d ated m en wh en she wa s yo u ng er b u t nev er l et t h em g et\ncl ose physica lly b eca use she beco me to o a nx ious wh en any int imacy b eg an to d ev elop.\nM s. D el gad o’s hist ory incl uded cu tting h er sel f su per ficia ll y o n a nu mber o f o cca sions, a lo ng\nwit h per sist ent t h ou gh ts th at sh e wo uld b e bet ter o ff d ea d. S h e sa id t h at sh e wa s gener ally\n“d own and d epr essed ” bu t t h at sh e had h ad d ozens of 1- t o 2 -d ay “m ania s” in wh ich sh e\nwa s ener giz ed a nd ed gy a nd pu lled a ll – nig hter s. S h e tend ed t o “cr ash ” th e nex t d ay a nd\nsl eep fo r 12 h ou rs.\nS h e had b een in psy chiatr ic tr ea tm ent since ag e 17 a nd h ad b een psy ch iatr ica lly\nh ospit aliz ed t h ree tim es aft er o verd oses. T rea tm ent s had co nsist ed pr im aril y o f\nm ed ica tio n: mood st ab il iz er s, l o w- dose neu ro lept ics, a nd a nt idepr essa nts th at h ad b een\npr escr ibed in va rio us co mbina tio ns in th e co ntex t o f su ppo rtiv e psy choth er apy .\nDuring t h e int erview, sh e wa s a ca su all y g ro om ed a nd so mewh at u nk em pt wo man wh o wa s\ncooper ativ e, co her ent , a nd g o al d ir ect ed. S h e wa s gener all y d ysph oric wit h a co nst rict ed\naffect b u t d id sm ile appr opr iatel y sev eral t im es. S h e descr ibed sh am e at h er po or\nper fo rm ance bu t a lso b el iev ed sh e wa s “o n Earth t o d o so mething g rea t.” Sh e descr ibed h er\nfa th er a s a spect acu la r su ccess, b u t h e wa s also a “M ach iavel lia n lo ser wh o wa s alwa ys\ntr y ing t o m anipu la te peo ple.” Sh e d escr ibed q u it ting j o b s beca use peo ple wer e\ndisr espect fu l. F or ex am ple, sh e sa id t h at wh en she wo rk ed a s a cl er k a t a d epa rtm ent st ore,\npeo ple wo uld o ft en be ru de or u na ppr ecia tiv e (“a nd I wa s th er e on ly in prepa ra tio n to\nb eco me a b u yer ; it wa s rid icu lo u s”) . T owa rd t h e end o f t h e init ial sessio n, sh e beca me ang ry\nwit h t h e int erviewer a ft er h e gla n ced a t t h e cl ock ( “A re yo u b ored a lr ea dy?”) . S h e sa id sh e\nknew people in th e neig hborh ood , b u t m ost o f t h em h ad “b eco me fr a u ds or l o ser s.” Ther e\nwer e a f ew peo ple fr o m sch ool wh o wer e “F aceb ook f r iend s,” doing a m azing t h ing s all o ver\nth e wo rld . A lt h ou gh sh e had no t seen th em in yea rs, sh e int end ed t o “m eet u p wit h t h em if\nt h ey ev er co me back t o t o wn. ”\nB ord er line persona lit y d iso rd er\nMs. D el gad o pr esent s wit h a ffect iv e inst ab il it y, d if ficu lt y co ntro ll ing h er a ng er, u nst ab le\nint erper sona l r el atio nsh ips, a n id ent ity d ist urb ance, sel f- m util ating b eh avio r, f eel ing s of\nem ptiness, a nd t r a nsient , st ress- rel ated pa ra no ia. S h e m eet s cr iter ia, t h er efore, f o r D SM -5\nb ord er line persona lit y d iso rd er ( B PD ).\nI nd ivid uals wit h B PD o ft en present wit h d epr essiv e and /or b ipo la r sy mpt om s, a nd M s.\nDel gad o is no ex cept ion. H er pr esent ing sy mpt om s incl ude a pr ed om ina ntly d epr essed\nmood , d im inish ed int erest s, o ver ea ting , a ner gia , a nd ch ro nic suicid al id ea tio n. D isa bling ,\nper sist ent f o r 6 m ont hs, a nd o ccu rring in th e ab sence of su bst ance u se or a m ed ica l\ndiso rd er , M s. D el gad o’s sy mpt om s also m eet cr iter ia f o r a D SM -5 m ajo r d epr essio n. S u ch\nco morb id ity b et ween BPD a nd d epr essio n is co mmon. I t is int erest ing t o no te th at M s.\nDel gad o’s pr eo ccu patio ns are accu sato ry , wh erea s th e ty pica l pr eo ccu patio n of a d epr essed\nperson wit hou t a per sona lit y d iso rd er is gu il ty a nd sel f- a ccu sato ry . I t wo uld b e wo rth\nex ploring t h e po ssib ilit y t h at M s. D el gad o’s depr essiv e sy mpt om s are m ore episo dic and\nrea ctive th an sh e init ially r epo rts. I t a lso seem s po ssib le th at sh e qu alif ies fo r l if el ong\nd epr essio n, wh ich wo uld ind icate d yst hym ic diso rd er b u t wo uld a lso po int t o wa rd a\nper sona lit y d iso rd er .\nM s. D el gad o r epo rts “m ania s” th at a re no t t y pica l o f so meo ne wit h b ipo la r d iso rd er . F or\nex am ple, sh e descr ibes having h ad d ozens of 1- t o 2 -d ay episo des in wh ich sh e is ener giz ed\nand ed gy, f o llo wed b y a “cr ash ” an d 12 h ou rs of sl eep. T hese do no t co nform t o t h e cr iter ia\nfo r b ipo la r I o r b ipo la r I I d iso rd er , in reg ard t o eit her sy mpt om s or d u ra tio n. T he\nem otio na l inst ab il it y a nd a ffect st orm s of B PD ca n lo ok v er y m uch l ik e a m anic or\nh ypo manic episo de, wh ich ca n lea d t o u nd erdia gno sis of B PD . E ven in th e pr esence of a\nsig nifica nt m anic episo de, t h e cl inicia n sh ou ld ex plore su ch h ist orica l v a ria bles as affect ive\nstab il it y, m atu rit y o f int erper sona l r el atio nsh ips, a nd st ab il it y o f wo rk , r el atio nsh ips, a nd\nsel f- a ssessm ent. I f pr ob lem s are fo u nd , a B PD d ia gno sis is lik ely.\nCr iter ia f o r D SM -5 per sona lit y d iso rd er s rem ain unch ang ed f r o m t h e pr evious\ncl assif icatio n sy stem . H owev er, t h e alt er na tiv e m od el f o r per sona lit y d iso rd er s, pr esent ed\nin DSM -5 S ect ion III, su ggest s a m ore dim ensio nal a ppr oach , o ne in wh ich t h e int erviewer\nwo uld ex plicit ly co nsid er per sona lit y f u nct ioning . T he append ix o u tlines fiv e dif fer ent t r a it\nd om ains th at ex ist o n a co ntinu um . “E motio na l st ab il it y” is co ntra st ed wit h “neg ativ e\naffect ivity,” fo r ex am ple, wh erea s “a nt ag o nism ” is at t h e oth er end o f t h e spect ru m f r o m\n“a greea bleness” (see Tab le 18 – in th e int ro d u ct io n to t h is ch apt er). 8/14/2019 Psychiatry Online | DSM Library\nThis dim ensio nal v iew of per sona lit y is co mpa tib le wit h K er nb erg’s lo ng -st and ing m od el o f\nb ord er line persona lit y o rg aniz atio n (B PO ). I n ad d it io n to m eet ing t h e D SM -5 cr iter ia f o r\nB PD , M s. D el gad o f it s th e cr iter ia f o r B PO —a psy cholo gica l st ru ct ure co nceiv ed a s being\nch ara ct er ized b y 1) l a ck o f a cl ea r a nd co her ent sense of sel f a nd o th er s (id ent ity d if fu sio n),\n2) f r eq uent u se of pr im itiv e def ense mech anism s based o n spl itting , a nd 3) int act b u t\nfr a g il e rea lit y t est ing . T he m ore int egra ted a nd r ea list ica lly co mplex t h e ind ivid ual’s\nr epr esent atio ns of sel f a nd o th er s are, t h e m ore th e ind ivid ual is ab le to m od u la te and\nco ntro l h is or h er em otio na l st ates and su ccessf ully int eract wit h o th er s.\nM s. D el gad o d em onst ra tes ident it y d if fu sio n in her co ntra d ict ory v iews of h er sel f ( a s both\nsu per ior a nd ina deq uate) a nd o th er s (h er f a th er a s both spect acu la r a nd a “M ach iavel lia n\nlo ser ”). H er d ef ensiv e st yle is ch ara ct er ized b y co nsist ent pr oject ion of h er h ost ile feel ing s\nand per ceiv ing t h e host ilit y a s co ming f r o m o th er s. T he fr a g il it y o f h er r ea lit y t est ing , seen\nin th e slig hts sh e fel t a t wo rk , h as led t o ch ro nic occu patio na l d ysf unct ion.\nBeca use peo ple wit h per sona lit y d iso rd er s oft en do no t pr esent a n int erper sona l na rra tiv e\nth at co nform s to t h e st ory t h at wo uld b e to ld b y o th er s, it is im porta nt t o a ttend t o t h e\npa tient ’s beh avio r in rel atio n to t h e th er apist . W ith M s. D el gad o, e v id ence of h er f r a g il it y is\nseen in her sense th at t h e th er apist ’s gla ncing a t t h e cl ock m ea nt h e did no t l ik e her a nd\nwa nted t o g et r id o f h er .\nSu icid al t end encies are pa rt o f b oth d epr essio n and B PD . I n gener al, a cu te or ch ro nic\npa ra su icid al b eh avio r is ty pica l o f sev ere per sona lit y d iso rd er s. F urth er more, su icid alit y\nca n dev elop ab ru pt ly d u ring cr ises am ong a v a riet y o f pa tient s, b u t it is especia lly pr evalent\nin peo ple—l ike M s. D el gad o—wit h a f r a g il e sense of b oth t h e wo rld a nd t h em selves.\nS u ggeste d R ead in gs\nCl ark in JF , Yeo mans F E , K er nb erg OF : Psy ch oth er apy f o r B ord er line Per so na lit y :\nFocu sing o n Object R el atio ns . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing , 2 0 06\nK er nb erg OF , Yeo mans F E : B ord er line persona lit y d iso rd er , b ipo la r d iso rd er , d epr essio n,\nattent ion def icit /hyper act ivity d is ord er , a nd na rcissist ic per sona lit y d iso rd er : pr act ica l\ndif fer ent ial d ia gno sis . B ull M enning er Cl in 77 (1): 1– 2 2 , 2 0 13 PubM ed I D : 2 34 28 16 9\nOld h am JM , S ko d ol A E , B end er DS ( ed s): Am er ica n Psy ch iatr ic Publish ing T ex tb ook o f\nP er so na lit y D iso rd er s , 2 nd E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing ( in 8/14/2019 Psychiatry Online | DSM Library\nT usia ni B , T usia ni PA , T usia ni- Eng P : R em nants of a L if e on Paper . N ew York , B aro q u e\nP ress , 2 0 13\nC ase 1 8.6 P ain fu l S u ic id alit y\nE lizab eth L . A uch in clo ss, M.D .\nKarm en Fuent es wa s a 5 0 -y ea r-o ld m arried H ispa nic woman wh o pr esent ed t o t h e\npsy chiatr ic em ergency r o om ( E R ) a t t h e urg ing o f h er o u tpa tient psy chiatr ist a ft er t el ling\nh im t h at sh e had b een th ink ing a b ou t o ver dosing o n Advil .\nIn th e ER , M s. F uent es explained t h at h er b ack h ad b een “killing ” her since she fel l sev eral\nd ays ea rlier a t t h e fa m ily-o wned g ro cer y st ore wh ere sh e had wo rk ed f o r m any y ea rs. T he\nfa ll h ad l ef t h er d ownca st a nd d ep ressed , a lt h ou gh sh e denied o th er d epr essiv e sy mpt om s\nasid e fr o m a po or m ood . S h e spo ke at l eng th a b ou t t h e fa ll a nd a b ou t h ow it r em ind ed h er\nof a f a ll t h at sh e had su stained a f ew yea rs ea rlier . A t t h at t im e, sh e h ad g o ne to see a\nneu ro su rg eo n, wh o t o ld h er t o r es t a nd t a k e no nst eroid al a nt i-inf la m mato ry d ru gs. S h e\ndescr ibed f eel ing “a band oned a nd no t ca red a b ou t” by h im . T he pa in had d im inish ed h er\nab il it y t o ex ercise, a nd sh e wa s upset t h at sh e had g ained weig ht. W hile rel ating t h e ev ent s\nsurro u nd ing t h e fa ll, M s. F uent es beg an to cr y.\nW hen ask ed a b ou t h er su icid al co mment s, sh e sa id t h ey wer e “no b ig d ea l.” Sh e repo rted\nth at t h ey wer e “just a t h rea t” aim ed a t h er h usb and t o “t ea ch h im a l esso n” beca use “he has\nno co mpa ssio n fo r m e” and h ad n ot b een suppo rtiv e since th e fa ll . S h e insist ed h er\nco mment s ab ou t o ver dosing d id n ot h ave oth er m ea ning . W hen her E R int erviewer\nex pressed co ncer n ab ou t t h e po ssib ilit y t h at sh e wo uld k il l h er sel f, sh e ex claim ed wit h a\nsm ile, “O h wo w, I d id n’t r ea liz e it’s so ser ious. I g u ess I sh ou ld n’ t d o t h at a g ain. ” Sh e th en\nsh ru gged a nd l a u gh ed . S h e went o n to t a lk a b ou t h ow “nice and sweet ” it wa s th at so m any\nd oct ors and so cia l wo rk er s wa nted t o h ea r h er st ory , ca lling m any o f t h em b y t h eir f ir st\nna mes. S h e wa s also so mewh at f li r ta tio us wit h h er m ale resid ent in ter viewer , wh o h ad\nm ent ioned t h at sh e wa s th e “b est -d ressed wo man in th e ER .”\nA cco rd ing t o h er o u tpa tient psy chiatr ist o f 3 yea rs, sh e had nev er b ef ore ex pressed su icid al\nid ea tio n unt il t h is week , a nd h e wo uld b e una ble to ch eck in on her u nt il a ft er h e lef t o n\nva ca tio n th e nex t d ay. M s. F uent es’ s husb and r epo rted t h at sh e ta lk ed a b ou t su icid e “lik e 8/14/2019 Psychiatry Online | DSM Library\noth er peo ple co mplain ab ou t t h e wea th er . S h e’ s ju st t r y ing t o g et m e wo rried , b u t it d oesn’ t\nwork a ny more. ” H e sa id h e wo uld nev er h ave su ggest ed sh e go t o t h e ER a nd t h ou gh t t h e\npsy chiatr ist h ad o ver rea cted .\nMs. F uent es init ially so ugh t o u tpa tient psy choth er apy a t a g e 47 b eca use she wa s feel ing\ndepr essed a nd u nsu ppo rted b y h er h usb and . D uring 3 yea rs of o u tpa tient t r ea tm ent , M s.\nFuent es had b een prescr ibed a d eq uate tr ia ls of ser tr a line, escit alo pr am , f lu oxet ine, a nd\npa ro xet ine. N one seem ed t o h el p.\nM s. F uent es descr ibed b eing “a n ea rly b lo om er .” Sh e beca me sex ually a ct ive wit h o ld er\nm en wh en she wa s in hig h sch ool. S h e sa id d ating h ad b een th e m ost f u n th ing sh e had ev er\ndone and t h at sh e m issed seeing m en “jum p th ro u gh h oops” to sl eep with h er . S h e liv ed\nwit h h er 7 3- yea r-o ld h usb and . H er 2 5-y ea r-o ld so n liv ed nea rb y wit h h is wif e and y o u ng\nso n. S h e descr ibed h er h usb and a s a “v ery f a m ou s” musicia n. S h e sa id t h at h e had nev er\nhel ped a ro u nd t h e hou se or wit h ch ild-r ea ring a nd d id no t a ppr ecia te how much wo rk sh e\npu t int o t a k ing ca re of t h eir so n and g ra nd son.\nH ist rio nic persona lit y d iso rd er\nM s. F uent es present s to t h e ER wit h d epr essio n and su icid alit y, b u t neit her o f t h ese\nsy mpt om s is as pr om inent a s her o ng oing pa tter n of ex cessiv e em otio na lit y a nd a ttent ion\nseek ing. H er b eh avio r wit h t h e ER st aff a nd per haps th e fa ll it sel f a ppea r t o ser ve a need f o r\nattent ion and ca re, a nd b oth M s. F uent es and h er h usb and d escr ibe her ch ro nic suicid al\nth rea ts as ef fo rts to pu nish a nd el icit co ncer n. F or ex am ple, t h e ER v isit wa s pr ecipit ated b y\nM s. F uent es mak ing h er f ir st su icid al t h rea t in tr ea tm ent j u st a s her d oct or wa s go ing o n\nva ca tio n, su ggest ing t h at sh e m ight h ave fel t l ef t o u t a nd a b and oned .\nMs. F uent es’s em otio ns shift r a pid ly b et ween tea rfu l a nd ch eer fu l, b u t sh e co nsist ently\nd ism isses th e act ual t h rea t o f su icid e. I nst ead, M s. F uent es fo cu ses on her d ra m atic fa ll,\na nd o n her per cept ion th at neit her h er h usb and no r h er neu ro su rg eo n appea rs to b e\nint erest ed in her su ffer ing . T hro u gh ou t h er E R v isit , sh e wa s sed uct ive wit h h er int erviewer\na nd u nu sually f r iend ly wit h st aff, ca ll ing m any o f t h em b y t h eir f ir st na mes. E ven in a b u sy\nE R , f il led wit h sick , inj ured , a nd p resu mab ly u nk em pt peo ple, M s. F uent es maint ains her 8/14/2019 Psychiatry Online | DSM Library\nconcer n ab ou t h er ph ysica l a ppea ra nce. S h e im plies th at h er d ress, g ro om ing , a nd weig ht\nare cent ra lly im porta nt t o h er sen se of sel f- est eem , a nd t h at sh e co ntinu es to pa y cl ose\nattent ion to t h eir m aint ena nce.\nThese ob ser va tio ns suggest t h at h er su icid alit y is no t pa rt o f a m ajo r a ffect ive diso rd er .\nInst ead, sh e has at l ea st six o f t h e eig ht sy mpt om atic criter ia f o r a D SM -5 d ia gno sis of\nh ist rio nic persona lit y d iso rd er ( H PD ): d isco mfo rt wh en not t h e cen ter o f a ttent ion;\nsed uct ive beh avio r; int ense bu t sh ifting a nd sh allo w em otio na lit y; th e use of ph ysica l\nappea ra nce to d ra w attent ion; sel f- d ra m atiz atio n and t h ea tr ica lit y; and a t end ency t o\nco nsid er r el atio nsh ips to b e m ore int imate th an th ey a re. W hile M s. F uent es does not sh ow\ncl ea r ev idence of o th er cr iter ia f o r H PD , su ch a s im pressio nistic sp eech a nd su ggest ibilit y,\nth ese may h ave sim ply no t b een incl uded in th e ca se repo rt.\nB eca use patient s wit h H PD o ft en have co morb id so matic sympt om d iso rd er s, ca ref ul\nattent ion sh ou ld b e giv en to ev alu ating t h e pa tient f o r t h ese diso rd er s. M s. F uent es has\nb een episo dica lly pr eo ccu pied wit h ph ysica l d isco mfo rt, a nd f u rth er ev alu atio n m ight\ndem onst ra te a m ore per va siv e an d im pairing pa tter n of ph ysica l co mplaint s or co ncer ns.\nPatient s wit h H PD a lso h ave el ev ated r a tes of m ajo r d epr essiv e diso rd er . I nd eed , M s.\nFuent es shows many sig ns of d ep ressed m ood . F urth er more, M s. F uent es wa s ref er red t o\nt h e ER b eca use of su icid alit y. A lt h ou gh sh e and h er h usb and m inim ize th e ser iousness of\nth ese th rea ts, H PD d oes appea r t o b e asso ciated wit h a n elev ated r isk o f su icid e attem pts.\nM any o f t h ese attem pts wil l b e su blet hal, b u t a v a riet y o f su icid al “g est ures” can lea d t o\nser ious harm a nd ev en sem i-accid ental d ea th . Cl inica l wo rk wit h M s. F uent es wil l inv olv e\nb ala ncing t h e reco gnit ion th at h er su icid al id ea tio n ser ves th e need f o r a ttent ion wit h\nawa reness th at it m ay a lso l ea d t o a ct ual sel f- h arm .\nAs in all psy chiatr ic assessm ents, cl inicia ns must co nsid er wh ether t h e per sona lit y issu es\nare a pr ob lem b ef ore m ak ing a d ia gno sis. N orm s fo r em otio na l ex pressiv eness,\ninterper sona l b eh avio r, a nd st yle of d ress va ry sig nifica ntly b et ween cult u res, g end ers, a nd\na g e gro u ps, a nd it is im porta nt no t t o g ra tu it ou sl y pa th olo giz e va ria tio ns th at a re no t\nacco mpa nied b y d ysf unct ion and d ist ress. A s an ex am ple of po tent ial b ia s, wo men are m ore\nfr eq uent ly d ia gno sed wit h H PD d espit e po pu la tio n studies th at ind icate th at H PD is\neq ually co mmon in men and wo men.\nHPD is oft en comorb id wit h o th er per sona lit y d iso rd er s. A lt h ou gh M s. F uent es has tr a it s\nth at a re co mmon to o th er per sona lit y d iso rd er s, sh e does not a ppea r t o h ave a seco nd 8/14/2019 Psychiatry Online | DSM Library\ndia gno sis. F or ex am ple, M s. F uent es’s su icid al t h rea ts and d ra m atic present atio n m ight\nlea d t h e ex am iner t o co nsid er b ord er line persona lit y d iso rd er . M s. F uent es does not,\nh owev er, sh ow th e m ark ed inst ab il it y in int erper sona l r el atio nsh ips, ex tr em e sel f-\nd est ru ct iveness, a ng ry d isr upt ions in int erper sona l r el atio nsh ips, a nd ch ro nic feel ing s of\nem ptiness th at a re co mmon in bord er line persona lit y d iso rd er . W hile M s. F uent es\ncomplains of no t r eceiv ing t h e ca re th at sh e wo uld l ik e, sh e does not m anif est t h e fea r o f\nsepa ra tio n and t h e so rt o f su bm issiv e and cl ing y b eh avio r t h at a re ty pica l o f d epend ent\npersona lit y d iso rd er . S im ilarly , a lt h ou gh sh e appea rs to h ave an ex cessiv e need f o r\nad m iratio n, sh e has no t d em onst ra ted t h e la ck o f em path y t h at is a ca rd ina l f ea tu re of\nna rcissist ic per sona lit y d iso rd er . F ina lly , wh ile sh e dem onst ra tes so m e m anipu la tiv e\nbeh avio r, a s do peo ple wit h a nt iso cial per sona lit y d iso rd er , h er s is motiv ated b y a d esir e fo r\nattent ion ra th er t h an so me so rt o f pr ofit .\nGa bbard GO : Cl ust er B per sona lit y d iso rd er s: hyst er ica l a nd h ist rio nic , in P sy ch od yna mic\nPsy ch iatr y in Clinica l P ra ct ice , 4 th E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic\nP ublish ing , 2 0 05 , pp 5 4 1 – 570\nH ales R E , Yu dofsk y SC , R ob er ts L W ( ed s): The Am er ica n Psy ch iatr ic Publish ing T ex tb ook\nof P sy ch iatr y , 6 th E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing , 2 0 14\nM acK inno n RA , M ich els R , B uck ley P J : T he hist rio nic patient , in T he Psy ch iatr ic\nInt erview in Clinica l P ra ct ice , 2 nd E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic\nP ublish ing , 2 0 06 , pp 137 – 17 6\nCase 1 8.7 D is sa tis fa ctio n\nR ob ert M ic h els, M .D .\nLarry Go ra no v wa s a 5 7-y ea r-o ld sing le unem ployed wh ite m an wh o wa s ask ing f o r a\nr ev iew of h is tr ea tm ent a t t h e psy chiatr ic clinic. H e had b een in we ekly psy choth er apy f o r 7\ny ea rs wit h a d ia gno sis of d yst hym ic diso rd er . H e co mplained t h at t h e tr ea tm ent h ad b een\nof l it tle hel p and h e wa nted t o m ak e su re th at t h e doct ors wer e on th e rig ht t r a ck .\nMr. Go ra no v r epo rted a l o ng -st and ing h ist ory o f l o w- gra d e depr essed m ood a nd d ecr eased\nener gy. H e had t o “d ra g ” him sel f o u t o f b ed ev ery m orning a nd r a rel y l o oked f o rwa rd t o 8/14/2019 Psychiatry Online | DSM Library\nany th ing . H e had l o st h is la st j o b 3 yea rs ea rlier , h ad b ro ken up wit h a g ir lf r iend sl ig htly\nla ter , a nd d ou bted t h at h e wo uld ev er wo rk o r d ate ag ain. H e wa s em barra ssed t h at h e st ill\nliv ed wit h h is moth er , wh o wa s in her 8 0 s. H e denied a ny im med iate int ent ion or pl an to\nk il l h im sel f, b u t if h e did no t im prove by t h e tim e his moth er d ied , h e did no t see what h e\nwo uld h ave to l iv e fo r. H e denied d ist urb ances in sleep, a ppet ite, o r co ncent ra tio n.\nCl inic reco rd s ind icated t h at M r. Go ra no v h ad b een ad h er ent t o a d eq uate tr ia ls of\nflu oxet ine, escit alo pr am , ser tr a lin e, d u lo xet ine, v enl afa x ine, a nd b u pr opio n, a s wel l a s\nau gm ent atio n wit h q u et iapine, a ripipr azo le, l it hiu m , a nd l ev oth yro xine. H e had so me\nim provem ent in his mood wh ile ta k ing escit alo pr am b u t d id no t h ave rem issio n of\nsy mpt om s. H e also h ad a co urse of co gnit ive- beh avio ra l t h er apy ea rly in his tr ea tm ent ; h e\nh ad b een dism issiv e of t h e th er ap ist a nd t r ea tm ent , d id no t d o h is assig ned h om ewo rk , a nd\na ppea red t o m ak e no ef fo rt t o u se th e th er apy b et ween sessio ns. H e had nev er t r ied\npsy chod yna mic psy choth er apy .\nMr. Go ra no v ex pressed f r u st ra tio n at h is la ck o f im provem ent , t h e na tu re of h is tr ea tm ent ,\nand h is specif ic th er apy . H e fo u nd it “h um ilia ting ” th at h e wa s fo rced t o see tr a inees who\nro ta ted o ff h is case every y ea r o r t wo . H e fr eq uent ly f o u nd t h at t h e psy chiatr y r esid ents\nwer e no t especia lly ed uca ted , cu lt u red , o r so ph istica ted , a nd f el t t h ey k new less ab ou t\npsy choth er apy t h an he did . H e m uch pr efer red t o wo rk wit h f em ale th er apist s, b eca use\nm en wer e “t oo co mpet itiv e and en vio us. ”\nM r. Go ra no v pr eviousl y wo rk ed a s an insu ra nce bro ker . H e ex plain ed , “I t’s rid icu lo u s. I\nwa s th e best b ro ker t h ey h ad ev er seen, b u t t h ey wo n’t r eh ire m e. I t h ink t h e pr ob lem is\nt h at t h e pr ofessio n is fil led wit h b ig eg os, a nd I ca n’t k eep my m ou th sh ut a b ou t it .” A ft er\nb eing “b la ck balled ” by insu ra nce ag encies, M r. Go ra no v d id no t wo rk f o r 5 y ea rs, u nt il h e\nwa s hir ed b y a n au to m ob il e dea ler . H e sa id t h at a lt h ou gh it wa s benea th h im t o sel l ca rs, h e\nwa s su ccessf ul, a nd “in no t im e, I wa s ru nning t h e pl ace. ” H e qu it w ithin a f ew mont hs aft er\na n arg u m ent wit h t h e owner . D espit e enco ura g em ent f r o m sev eral t h er apist s, M r. Go ra no v\nhad no t a ppl ied f o r a j o b o r pu rsu ed em ploym ent r eh ab il it atio n or v o lu nt eer wo rk ; h e\nst ro ng ly v iewed t h ese opt ions as benea th h im .\nMr. Go ra no v h as “g iven up on wo men. ” H e had m any pa rtner s as a y o u ng er m an, b u t h e\ngener ally f o u nd t h em t o b e una ppr ecia tiv e and “o nly in it f o r t h e fr ee mea ls. ” The\npsy chiatr ic resid ent no tes ind icated t h at h e respo nded t o d em onst ra tio ns of int erest wit h\nsuspicio n. T his tend ency h el d t r u e in reg ard t o b oth wo men wh o h ad t r ied t o b ef riend h im 8/14/2019 Psychiatry Online | DSM Library\nand r esid ents wh o h ad t a k en an in ter est in his care. M r. Go ra no v d escr ibed h im sel f a s\nso meo ne wh o h ad a l o t o f l o ve to g iv e, b u t sa id t h at t h e wo rld wa s fu ll o f m anipu la to rs. H e\nsa id h e had a f ew bu ddies, b u t h is m oth er wa s th e onl y o ne he tr u ly ca red a b ou t. H e\nenj oyed f ine rest au ra nt s and “f iv e-st ar h otel s,” bu t h e ad d ed t h at h e co uld no l o ng er a ffo rd\nth em . H e ex ercised d ail y a nd wa s co ncer ned a b ou t m aint aining h is b od y. M ost o f h is tim e\nwa s spent a t h om e wa tch ing t el ev isio n or r ea ding no vel s and b io gra ph ies.\nOn ex am ina tio n, t h e pa tient wa s nea tly g ro om ed , h ad sl ick ed-b ack h air , a nd wo re cl oth ing\nth at a ppea red t o b e by a h ip- hop desig ner g ener all y f a vo red b y m en in th eir 2 0 s. H e wa s\ncoher ent , g o al d ir ect ed, a nd g ener all y co oper ativ e. H e sa id h e wa s sa d a nd a ng ry . H is affect\nwa s co nst rict ed a nd d ism issiv e. H e denied a n int ent ion to k il l h im sel f b u t f el t h opel ess and\nth ou gh t o f d ea th f a ir ly o ft en. H e wa s co gnit ively int act .\nD ia g n osis\nN arcissist ic per sona lit y d iso rd er\nW hen a pa tient pr esent s to a psy chiatr ist , sy mpt om s are gener all y t h ose aspect s of\npsy chopa th olo gy t h at a re ea siest t o r eco gniz e and t o d ia gno se. A nx iet y, d epr essio n,\nob sessio ns, a nd ph ob ia s are seen similarly b y pa tient a nd d oct or a nd a re cent ra l d ef ining\nch ara ct er ist ics of m any d iso rd er s. P atient s wit h per sona lit y d iso rd er s are dif fer ent . T heir\npr ob lem s are oft en more dist ressi ng t o o th er s th an to t h e pa tient , a nd t h eir sy mpt om s are\no ft en va g u e and m ay seem seco ndary t o t h eir cent ra l issu e. W hat d et er mines th e dia gno sis\nor d ef ines th e fo cu s of t r ea tm ent is no t t h e anx iet y o r d epr essio n, f o r ex am ple, b u t r a th er\nwh o t h e pa tient is, t h e lif e he or sh e has ch osen to l ea d, a nd t h e pa tter n of h is or h er h um an\nrel atio nsh ips.\nA co ro lla ry is th at t h e pa tient ’s co mplaint s m ay b e less rev ea ling t h an th e wa y in wh ich t h ey\nare m ad e. T he co nsu lt a tio n int erview with m ost pa tient s co nsist s of co llect ing inf orm atio n\nand m ak ing o b ser va tio ns. T he co nsu lt a tio n wit h m ost pa tient s wh o h ave per sona lit y\ndiso rd er s req uir es th e cr ea tio n of a r el atio nsh ip, a nd t h en th e doct or’s ex per iencing a nd\nu nd erstand ing o f t h at r el atio nsh ip. Co unt ertr a nsf erence respo nses can be im porta nt\nd ia gno stic to ols, a nd t h e wa y in which t h e pa tient r el ates to t h e cl inicia n ref lect s th e\ntem plate th at st ru ct ures how th e pa tient r el ates to o th er s. F or ex am ple, M r. Go ra no v’s\npr im ary co mplaint is his sad m ood . A lt h ou gh h e co uld h ave a d epr essiv e diso rd er , h e seem s 8/14/2019 Psychiatry Online | DSM Library\nto l a ck m ost o f t h e per tinent D SM -5 cr iter ia f o r a ny o f t h e depr essiv e diso rd er s. I nst ead, h is\nlo w mood a ppea rs to b e a r espo nse to ch ro nic disa ppo intment . D espit e his view of h im sel f\nas ta lent ed a nd a ttr a ct ive, h e is unem ployed , u nd erappr ecia ted , a nd a lo ne. E m pt y\ndem ora liz atio n is a co mmon acco mpa nim ent t o per sona lit y d iso rd er a nd , a s wit h M r.\nGo ra no v, is oft en unr espo nsive to ph arm aco th er apy .\nFurth er , a ty pica l f o r m ost pa tient s wit h ser ious depr essio n, h e is co ncer ned a b ou t\nm aint aining h is appea ra nce and h is attr a ct iveness to o th er s. H is gro om ing , cl oth es, a nd\nm anner r ef lect h is und erly ing g ra nd iosit y, h is co nv ict ion th at h e is specia l a nd d eser ving o f\nth e appr ecia tio n th at h e has fa il ed t o r eceiv e.\nThis story a b ou t M r. Go ra no v r ef lect s a t y pica l m ild t o m od er ate na rcissist ic per sona lit y\ndiso rd er . Cl assic fea tu res incl ude gra nd iosit y, a co nv ict ion th at h e deser ves specia l\ntr ea tm ent , est ra ng em ent f r o m o th er s, a st rik ing ly d im inish ed ca pa cit y f o r em path y, a nd a n\nattit ude of a rro gant d isd ain. T he depr essed a ff ect is clea rly pr esent , b u t it is seco ndary t o\nh is fu nd am ent al per sona lit y psy ch opa th olo gy.\nT hese patient s are dif ficu lt t o t r ea t. T hey see th eir pr ob lem a s th e fa il ure of t h e wo rld t o\nr eco gniz e th eir t r u e va lu e, a nd t h ey o ft en slid e int o d epr essed , l o nel y so cia l wit hdra wa l a s\nlif e pr ogresses. A t h er apeu tic allia nce req uir es mak ing co ntact wit h t h em a ro u nd t h eir\npa in, l o nel iness, a nd iso la tio n, a nd wo rk ing t o enh ance th eir pl ea su re ra th er t h an to\nr eno unce th eir cl aim s on oth er s.\nM r. Go ra no v is a pa tient . H e is no t j u st so meo ne wit h a so cia l a nd per sona l id ent ity wh o\nhappens to b e a pa tient ; b eing a p atient h as beco me cent ra l t o wh o h e is. F urth er more, h e\nis a d issa tisf ied pa tient , a nd h is psy chiatr ist d oes not pr ovid e him w ith wh at h e wa nts or\nfeel s ent itled t o g et . I n fa ct , a s his st ory u nf old s, it is clea r t h at t h is is a f a m ilia r pr ob lem f o r\nM r. Go ra no v. H e is dissa tisf ied w ith h is fr iend s, h is jo b s, a nd h is signif ica nt o th er s. L ik e his\nth er apist s, t h ey h ave no t b een go od eno ugh , h ave fa il ed t o r eco gniz e his va lu e, a nd h ave\nfa il ed h im .\nAkh ta r S: T he sh y na rcissist , in Ch ang ing I d ea s in a Ch ang ing W orld : T he Rev olu tio n in\nPsy ch oana ly sis. E ssa ys in Hono ur o f A rno ld Co oper . E dit ed b y S and ler J, M ich els R ,\nFona gy P . L ond on, K arna c , 2 0 00 , pp 111 – 119 8/14/2019 Psychiatry Online | DSM Library\nCooper A M : Furth er d ev elopm ents of t h e dia gno sis of na rcissist ic per sona lit y d iso rd er , in\nD iso rd er s of N arcissism : D ia gno stic, Cl inica l, a nd E m pir ical I m plica tio ns . E dit ed b y\nR onning stam E F . W ash ing to n, D C , A m er ica n Psy ch iatr ic Press , 19 98 , pp 5 3 – 74\nR onning stam E F ( ed ): D iso rd er s of N arcissism : D ia gno stic, Cl inica l, a nd E m pir ical\nIm plica tio ns . W ash ing to n, D C , A m er ica n Psy ch iatr ic Press , 19 98\nR onning stam E F , W einb erg I: Narcissist ic per sona lit y d iso rd er : pr ogress in reco gnit ion\nand t r ea tm ent . F ocu s 11 (2): 16 7 – 177 , 2 0 13\nC ase 1 8.8 S h yn ess\nJ . Ch rist op h er P erry , M .P .H. , M .D .\nM ath ilda H er ber t wa s a 2 3- yea r-o ld wo man ref er red f o r psy chiatr ic co nsu lt a tio n to h el p\nher “b rea k o u t o f h er sh ell.” Sh e had r ecent ly m oved t o a new city t o t a k e cl asses to b eco me\nan ind ust ria l l a b t ech nicia n and h ad m oved in wit h a n old er co usin, wh o wa s also a\npsy choth er apist a nd t h ou gh t sh e sh ou ld “g et o u t a nd enj oy h er y o u th .”\nA lt h ou gh sh e had pr eviousl y b een pr escr ibed m ed ica tio ns fo r a nx iet y, M s. H er ber t sa id\nth at h er r ea l pr ob lem wa s “sh ynes s.” Sch ool wa s dif ficu lt b eca use everyo ne was co nst ant ly\n“cr iticiz ing.” Sh e avo id ed b eing ca ll ed o n in class beca use she knew she wo uld “sa y\nsomething st upid ” and b lu sh a nd ev eryo ne would m ak e fu n of h er . S h e avo id ed spea king\nu p or t a lk ing o n tel eph ones, wo rried a b ou t h ow sh e wo uld so und . S h e drea ded pu blic\nspea king .\nSh e wa s sim ilarly r et icent wit h f r iend s. S h e sa id sh e had a lwa ys been a peo ple pl ea ser wh o\nprefer red t o h id e her f eel ing s wit h a ch eer fu l, co mpliant , a ttent ive dem eano r. S h e had a f ew\nfr iend s, wh om sh e descr ibed a s “wa rm a nd l if el ong .” Sh e fel t l o nel y a ft er h er r ecent m ove\na nd h ad no t y et m et a ny one fr o m sch ool o r t h e lo ca l co mmunit y.\nS h e sa id sh e had b ro ken up wit h h er f ir st ser ious boyfr iend 2 y ea rs ea rlier . H e had init ially\nb een “kind a nd pa tient ” and , t h ro u gh h im , sh e had a so cia l l if e by pr oxy. S oon aft er sh e\nmoved in wit h h im , h owev er, h e tu rned o u t t o b e an “a ng ry a lco holic. ” Sh e had no t d ated\nsince th at ex per ience. 8/14/2019 Psychiatry Online | DSM Library\nMs. H er ber t g rew up in a m etro po lit an area wit h h er pa rent s and t h ree old er sib ling s. H er\nbro th er wa s “h yper act ive and a nt iso cial” and t o ok u p ev eryo ne’ s attent ion, wh erea s her\nsist ers wer e “h yper compet itiv e an d per fect .” H er m oth er wa s anx iousl y co mpliant , “l ik e\nm e.” M s. H er ber t’s fa th er wa s a v er y su ccessf ul inv estment m ana ger wh o o ft en point ed o u t\nwa ys in wh ich h is ch ildren did no t l iv e up to h is ex pect atio ns. H e co uld b e su ppo rtiv e bu t\ntend ed t o d isr egard em otio na l u n cer ta int y in fa vo r o f a “t ou gh o pt im ism .” Tea sing a nd\nco mpet itio n “sa tu ra ted ” th e hou seh old , a nd “it d id n’t h el p th at I wa s fo rced t o g o t o t h e\nsa me gir ls’ sch ool wh ere m y sist ers had b een stars and wh ere ev eryo ne was rich a nd ca tty .”\nS h e dev eloped a k een sensit ivity t o cr iticism a nd f a il ure.\nH er pa rent s div orced d u ring h er s enio r y ea r o f h ig h sch ool. H er f a th er m arried a no th er\nwo man so on th er ea ft er . A lt h ou gh sh e had pl anned t o a ttend t h e sa me el ite univ ersit y a s\nh er t wo sist ers, sh e ch ose to a ttend a l o ca l co mmunit y co lleg e at t h e la st m inu te. S h e\nex plained t h at it wa s go od t o b e awa y f r o m a ll t h e co mpet itio n, a nd h er m oth er need ed t h e\nsu ppo rt.\nM s. H er ber t’s st reng th s incl uded ex cel lent wo rk in her m ajo r, ch em istry , especia lly a ft er\no ne senio r pr ofesso r t o ok a specia l int erest . F am ily ca mping t r ips had l ed t o a m ast er y o f\nou td oor sk ills, a nd sh e fo u nd t h at sh e enj oyed b eing o u t in th e wo od s, f lex ing h er\nind epend ence. S h e also enj oyed b ab ysit ting a nd v o lu nt eer ing in an im al sh elter s, b eca use\nkid s and a nim als “a ppr ecia te ev eryth ing y o u d o a nd a ren’ t m ea n.”\nDuring t h e ev alu atio n, M s. H er ber t wa s a wel l- d ressed y o u ng wo man of sh ort st atu re wh o\nwas attent ive, co her ent , a nd g o al d ir ect ed. S h e sm iled a l o t, especia lly wh en ta lk ing a b ou t\nth ing s th at wo uld h ave m ad e m ost peo ple ang ry . W hen th e psy chiatr ist o ffer ed a t r ia l\nco mment , l ink ing M s. H er ber t’s cu rrent a nx iet y t o ex per iences with h er f a th er , t h e pa tient\na ppea red q u iet ly u pset . A ft er sev era l su ch inst ances, t h e psy chiatr ist wo rried t h at a ny\nint erpr etive co mment s m ight b e ta k en as cr iticism a nd h ad t o ch eck a t end ency t o a vo id\nsensit ive su bject s. E xpl icit ly d iscu ssing h is co ncer ns led b oth t h e patient a nd psy chiatr ist t o\nr el ax a nd a llo wed t h e co nv ersa tio n to co ntinu e m ore pr od u ct ively.\nD ia g n ose s\nA vo id ant per sona lit y d iso rd er\nSocia l a nx iet y d iso rd er 8/14/2019 Psychiatry Online | DSM Library\nDis c u ssio n\nM s. H er ber t’s sh yness extend s int o a per sist ent so cia l a vo id ance th at r ed uces her a b il it y t o\nenj oy h er sel f. S h e und erper fo rm s a t sch ool, a nd sh e seem s to h ave ch osen her co lleg e (a\nlo ca l co mmunit y co lleg e) a nd ca re er ( la b t ech nicia n) l a rg el y t o r ed uce per ceiv ed r isk a nd t o\na vo id a nx iet y. S h e feel s lo nel y b u t is una ble to m ak e co nnect ions wit h f r iend s. S h e is\nst ym ied in her ef fo rts to d ate m en . S h e appea rs to h ave two D SM -5 d ia gno ses th at a re so\noft en comorb id t h at t h ey m ay b e dif fer ing co ncept ualiz atio ns of sim ilar co nd itio ns:\navo id ant per sona lit y d iso rd er ( A vP D ) a nd so cia l a nx iet y d iso rd er ( so cia l ph ob ia ).\nA vP D r ef lect s a per sist ent pa tter n of so cia l inh ibitio n, f eel ing s of ina deq uacy , a nd\nh yper sensit ivity t o neg ativ e ev alu atio n. I t a lso r eq uir es fo u r o r m ore of sev en criter ia,\nwh ich M s. H er ber t ea sil y m eet s. S h e avo id s occu patio na l a ct ivities th at inv olv e sig nifica nt\ninterper sona l co ntact . F or m ost o f h er l if e, sh e has been rel uct ant t o spea k u p, f ea ring t o\nd ra w criticism o r r id icu le, ev en fr o m f a m ily m em ber s. S h e avo id s being t h e cent er o f\nattent ion, is sel f- d ou bting , a nd b lu sh es easil y. S h e avo id s new situatio ns. S h e is unwil ling\nt o g et inv olv ed wit h peo ple unl ess she is cer ta in th at sh e wil l b e lik ed . T hese have had a\nd eb ilit ating ef fect o n all a spect s of h er l if e.\nLik e m ost peo ple wit h A vP D , M s. H er ber t a lso q u alif ies fo r D SM -5 so cia l a nx iet y d iso rd er\n(so cia l ph ob ia ). S h e dem onst ra tes fea r o f so cia l scr utiny a nd o f b ei ng neg ativ ely ev alu ated .\nSocia l sit uatio ns are end ured , b u t b arel y, a nd h er a nx iet y is alm ost a lwa ys pr esent . S h e\nappea rs sh y, sel ect s wo rk wh ere th er e wil l b e lim ited so cia l int eract io n, a nd pr efer s to l iv e\nwit h f a m ily m em ber s.\nM s. H er ber t d escr ibes having t h ese sympt om s fr o m a y o u ng a g e. A lt h ou gh sh yness is\ncommonl y r epo rted in ind ivid uals wit h A vP D a nd so cia l a nx iet y d iso rd er , m ost sh y\nch ildren do no t g o o n to r epo rt t h e so rts of issu es prevalent in peo ple wit h t h ese diso rd er s:\ndim inish ed sch ool per fo rm ance, em ploym ent , pr od u ct ivity, so cio eco no mic statu s, q u alit y\nof l if e, a nd o ver all wel l- b eing .\nDuring t h e int erview, t h e psy chiatr ist sensed M s. H er ber t’s dist res s and f el t\nunch ara ct er ist ica lly r est rict ed in what h e co uld a sk . I n oth er wo rd s, h e beca me awa re of a\nco unt ertr a nsf erence rea ctio n in wh ich h e fea red h urting h er f eel ing s. A ft er h e sh ared h is\nown concer ns th at sh e wo uld f eel cr iticiz ed b y h is co mment s, b oth t h e psy chiatr ist a nd t h e\npa tient wer e ab le to m ore co mfo rta b ly ex plore her h ist ory a nd d eepen th e th er apeu tic 8/14/2019 Psychiatry Online | DSM Library\nallia nce. A st ro ng a llia nce hel ps mitig ate dist ress and sh am e and incr eases th e lik elih ood o f\na m ore th oro u gh ex plora tio n fo r co mmon co morb id ities as wel l a s a sm ooth er t r a nsit ion\nint o t r ea tm ent .\nPer ry JC : Cl ust er C per sona lit y d iso rd er s : avo id ant , o b sessiv e-co mpu lsiv e, a nd\nd epend ent , in Ga bbard ’s Trea tm ent s of P sy ch iatr ic Diso rd er s , 5 th E dit io n . E dit ed b y\nGa bbard GO . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing ( in press )\nSanisl ow CA , B arto lini E E , Z olo th E C : A vo id ant per sona lit y d iso rd er , in E ncy cloped ia o f\nH um an Beh avio r , 2 nd E dit io n . E dit ed b y R am ach and ra n VS . S an Dieg o, CA , A ca dem ic\nPress , 2 0 12 , pp 2 57 – 2 6 6\nC ase 1 8.9 L ack o f S elf – C on den ce\nR ay mo nd R aad , M .D ., M .P .H.\nP au l S. A ppelb au m, M.D .\nNate Ir v in wa s a 31- yea r-o ld wh ite m an wh o so ugh t o u tpa tient psy chiatr ic ser vices fo r “l ack\no f sel f- co nfidence. ” H e repo rted l if el ong t r o u bles wit h a sser tiv enes s and wa s specif ically\nu pset b y h aving b een “stuck ” fo r 2 y ea rs at h is cu rrent “d ea d-end ” jo b a s an ad m inist ra tiv e\nassist ant . H e wish ed so meo ne would t el l h im wh ere to g o nex t so t h at h e wo uld no t h ave to\nfa ce th e “b urd en” of d ecisio n. A t w ork , h e fo u nd it ea sy t o f o llo w his boss’ s dir ect ions bu t\nh ad d if ficu lt y m ak ing ev en mino r ind epend ent d ecisio ns. T he sit uatio n wa s “d epr essing ,”\nh e sa id, b u t no th ing new.\nM r. I r v in also r epo rted d issa tisf actio n wit h h is rel atio nsh ips with w om en. H e descr ibed a\nser ies of sev eral- m ont h-lo ng r el atio nsh ips over t h e pr ior 10 y ea rs th at end ed d espit e his\ndoing “ev eryth ing I co uld .” H is most r ecent r el atio nsh ip had b een with a n oper a sing er. H e\nrepo rted h aving g o ne to sev eral o per as and t a k en sing ing cl asses to im press her , ev en\nth ou gh h e did no t pa rticu la rly enj oy m usic. T hat r el atio nsh ip had r ecent ly end ed f o r\nu ncl ear r ea sons. H e sa id h is mood a nd sel f- co nfidence were tied t o h is dating . B eing sing le\nm ad e him f eel d esper ate, b u t d esper atio n m ad e it ev en hard er t o g et a g ir lf r iend . H e sa id h e\nfel t t r a pped b y t h at spir al. S ince th e la test b rea ku p, h e had b een qu it e sa d, wit h f r eq uent\ncr ying spel ls. I t wa s th is depr essio n th at h ad pr om pt ed h im t o seek t r ea tm ent . H e denied 8/14/2019 Psychiatry Online | DSM Library\nall o th er sy mpt om s of d epr essio n, incl uding pr ob lem s wit h sl eep, a ppet ite, ener gy,\nsu icid alit y, a nd a b il it y t o enj oy t h ing s.\nMr. I r v in init ially d enied t a k ing a ny m ed ica tio ns, b u t h e ev ent uall y r ev ea led t h at 1 yea r\nearlier h is pr im ary ca re ph ysicia n h ad b eg un to pr escr ibe alpr azo la m 0 .5 m g/d ay f o r\n“a nx iet y.” H is dose had esca la ted , a nd a t t h e tim e of t h e ev alu atio n, M r. I r v in wa s ta k ing 5\nm g/d ay a nd g et ting pr escr iptions fr o m t h ree dif fer ent ph ysicia ns. Cu tting b ack l ed t o\na nx iet y a nd “t he sh ak es. ”\nMr. I r v in denied a ny pr ior per sona l o r f a m ily psy chiatr ic hist ory , in cluding o u tpa tient\npsy chiatr ic appo intment s.\nAft er h ea ring t h is hist ory , t h e psy chiatr ist wa s co ncer ned a b ou t M r. I r v in’ s esca la ting\na lpr azo la m u se and h is ch ro nic dif ficu lt ies with ind epend ence. S h e th ou gh t t h e m ost\naccu ra te dia gno sis was benz od ia zepine use diso rd er co morb id wit h a per sona lit y d iso rd er .\nHowev er, sh e wa s co ncer ned a b ou t t h e neg ativ e unint ended ef fect s t h at t h ese dia gno ses\nmight h ave on th e pa tient , incl uding h is em ploym ent a nd insu ra nc e co ver ag e, a s wel l a s\nh ow he wo uld b e dea lt wit h b y f u tu re cl inicia ns. S h e ty ped int o t h e el ect ro nic med ica l\nreco rd a d ia gno sis of “a dju st m ent d iso rd er wit h d epr essed m ood .” T wo week s la ter , M r.\nIr v in’ s insu ra nce compa ny a sk ed h er h is dia gno sis, a nd sh e gave th e sa me dia gno sis.\nD epend ent per sona lit y d iso rd er\nB enz od ia zepine use diso rd er\nM r. I r v in has an ex cessiv e need f o r so meo ne to t a k e ca re of h im a nd m ak e decisio ns fo r\nh im . H e has dif ficu lt y m ak ing d ecisio ns ind epend ently a nd wish es t h at o th er s wo uld m ak e\nth em f o r h im . H e la ck s th e co nfidence to init iate pr oject s or d o t h ing s on his own, h e\ngener ally f eel s unco mfo rta b le bei ng a lo ne, a nd h e is rel uct ant t o d isa gree on ev en mino r\nmatter s. H e go es to a lm ost d espe ra te leng th s to seek a nd m aint ain r el atio nsh ips and t o\no b ta in suppo rt a nd nu rtu ring f r o m o th er s.\nM r. I r v in, t h er efore, m eet s at l ea st six o f t h e eig ht D SM -5 cr iter ia ( o nl y f iv e are req uir ed )\nfo r d epend ent per sona lit y d iso rd er. T o m eet t h e cr iter ia f o r t h e dia gno sis, t h ese patter ns 8/14/2019 Psychiatry Online | DSM Library\nmust a lso f it t h e gener al cr iter ia f o r a per sona lit y d iso rd er ( i. e. , t h e sy mpt om s m ust d if fer\nfr o m cu lt u ra l ex pect atio ns and b e end uring , inf lex ible, per va siv e, a nd a sso ciated wit h\ndist ress and /or im pairm ent in fu nct ioning ). M r. I r v in’ s sy mpt om s m eet t h is stand ard .\nF urth er more, h is sympt om s are per sist ent a nd d eb ilit ating , a nd l ie ou tsid e th e no rm al\nex pect atio ns fo r a h ea lt h y a d u lt m an of h is ag e.\nM any psy chiatr ic dia gno ses can int ensif y d epend ent per sona lit y t r a it s or b e co morb id wit h\ndepend ent per sona lit y d iso rd er . I n th is pa tient , it is especia lly im porta nt t o co nsid er a\nm ood d iso rd er , b eca use he pr esent s wit h “d epr essio n” th at h as recent ly wo rsened . S om e\npa tient s wit h m ood d iso rd er s ca n pr esent wit h sy mpt om s th at m im ic per sona lit y d iso rd er s,\nso if t h is pa tient is in th e m idst o f a m ajo r d epr essiv e episo de, h is depend ent sy mpt om s\nmay b e co nfined t o t h at episo de. M r. I r v in, h owev er, d enies oth er sy mpt om s of d epr essio n\nand d oes not m eet cr iter ia f o r a ny o f t h e depr essiv e diso rd er s.\nNota b ly , M r. I r v in is using a lpr azo la m . H e has been ta k ing t h e m ed ica tio n in incr easing\nam ou nt s over a l o ng er per iod o f t im e th an wa s int end ed. T o o b ta in a n ad eq uate su ppl y, h e\nget s pr escr iptions fr o m t h ree dif fe rent ph ysicia ns. H e has dev eloped t o ler ance (r esu lt ing in\nd ose esca la tio n) a nd wit hdra wa l ( a s dem onst ra ted b y a nx iet y a nd sh ak es) . A ssu ming t h at\nfu rth er ex plora tio n wo uld co nfirm cl inica ll y sig nifica nt im pairm en t o r d ist ress, M r. I r v in\nm eet s cr iter ia f o r a b enz od ia zepine use diso rd er . Giv en his hist ory o f u se and h is tend ency\nnot t o b e ent irel y t r a nspa rent , it wo uld b e especia lly im porta nt t o t a ct fu lly ex plore th e\npo ssib ilit y t h at h e is using o th er su bst ances, incl uding a lco hol, t o b acco , il licit d ru gs, a nd\npr escr iption dru gs su ch a s opio ids.\nThe psy chiatr ist in th is case fa ces a co nflict co mmon in clinica l pr act ice. D ocu ment atio n of\npa tient s’ d ia gno ses in clinica l ch arts—a nd t h eir r el ea se to t h ir d pa rties—ca n so metim es\nhave downst rea m ef fect s on pa tie nt s’ insu ra nce cover ag e or d isa bil it y st atu s and ca n lea d t o\nst ig m atiz atio n, b oth wit hin and o u tsid e th e hea lt h ca re sy stem . Giv en th is rea lit y,\npsy chiatr ist s ca n be tem pted t o r eco rd o nl y t h e lea st sev ere of sev era l d ia gno ses, o r\nso metim es to r epo rt ina ccu ra te bu t pr esu mab ly l ess pejora tiv e diso rd er s. I n th is case, t h e\npsy chiatr ist d oes both . A lt h ou gh t h e pa tient h as depr essed m ood , h e does not m eet cr iter ia\nfo r t h e ad ju st m ent d iso rd er t h at is reco rd ed b y h is psy chiatr ist . H e d oes, h owev er, a ppea r\nto m eet cr iter ia f o r b oth d epend ent per sona lit y d iso rd er a nd b enz od ia zepine use diso rd er ,\nbu t neit her o f t h ese more ser ious and po tent iall y m ore st ig m atiz ing d ia gno ses is incl uded\nin th e ch art o r d iscl osed t o t h e ins urer . 8/14/2019 Psychiatry Online | DSM Library\nWhen dia gno ses are ina ccu ra tel y r eco rd ed in med ica l ch arts, o st en sib ly f o r t h e pu rpo se of\npr otect ing pa tient s, t h is may end u p ca using h arm inst ead. S u bseq uent cl inicia ns wh o\nrev iew th e reco rd s m ay l a ck cr itic al inf orm atio n reg ard ing pa tient s’ pr esent atio n and\ntr ea tm ent . F or ex am ple, if M r. I r v in wer e to u rg ent ly ca ll f o r a pr escript ion of\nb enz od ia zepines, a co ver ing psy chiatr ist m ight h ave no wa y o f k no wing f r o m t h e pa tient ’s\nch art a b ou t eit her t h e pa tter n of b enz od ia zepine ab u se or t h e ph ysio lo gica l d epend ence. A s\na ph ysicia n wh o int end s to “d o no h arm ,” M r. I r v in’ s psy chiatr ist h as tr ied t o sh iel d h im\nfr o m st ig m a b u t h as inst ead ex po sed h im t o m ed ica l r isk .\nThe ph ysicia n has oth er r espo nsibilit ies bey ond t h ose to t h e pa tien t. W hen th e ph ysicia n\nand pa tient a g ree to a ccept pa ym ent f r o m a n insu rer , t h e ph ysicia n m ay b e ob lig ated t o\npr ovid e to insu rer s and g o ver nm ental a g encies a r ea sona ble am ou nt o f h onest cl inica l\ninform atio n. L ack o f d iscl osu re is ta nt am ou nt t o f r a u d a nd ca n be pr osecu ted . I n ad dit io n,\nalt h ou gh b eing pa rt o f t h e m ed ica l pr ofessio n aff o rd s m any pr ivileg es, it a lso inv olv es\nrespo nsibilit ies. D ia gno stic deceit m ay seem l ik e an inno cuou s ef fo rt t o pr otect t h e pa tient ,\nbu t t h e dish onest y neg ativ ely a ffect s th e repu ta tio n of t h e ent ire pr ofessio n, a r epu ta tio n\nth at is int egra l t o t h e ab il it y t o r end er t r ea tm ent t o f u tu re pa tient s.\nAppel bau m P S : Priv acy in psy chiatr ic tr ea tm ent : th rea ts and r espo nses . A m J Psy ch iatr y\n15 9 (11 ): 18 09 – 18 18 , 2 0 02 PubM ed I D : 12 4112 11\nHowe E : Co re et hica l q u est ions : wh at d o y o u d o wh en yo u r o b lig atio ns as a psy chiatr ist\nco nflict wit h et hics? P sy ch iatr y 7(5): 19 – 2 6 , 2 0 10 PubM ed I D : 2 0 532 154\nMullins- Swea tt S N , B er nst ein DP , W idiger TA : R et ent ion or d el et io n of per sona lit y\ndiso rd er d ia gno ses fo r D SM -5 : a n ex per t co nsensu s appr oach . J Per s D iso rd 2 6 (5): 6 8 9 –\n70 3 , 2 0 12 PubM ed I D : 2 30 13338\nCase 1 8.1 0 R ela tio n sh ip C on tr o l\nM ic h ae l F. Walton , M .D .\nOgd en Judd a nd h is boyfr iend , P eter K leinm an, pr esent ed f o r co upl es th er apy t o a d dress\nesca la ting co nflict a ro u nd t h e issu e of m oving in to get her . M r. K leinm an descr ibed a\nsev eral- m ont h-lo ng a pa rtm ent se arch t h at wa s m ad e “a go niz ing ” by M r. Ju dd’s rig id wo rk 8/14/2019 Psychiatry Online | DSM Library\nschedule and h is “end less” list o f a pa rtm ent d em and s. T hey wer e una ble to co me to a\nd ecisio n, a nd ev ent ually t h ey d ecid ed t o j u st sh are M r. Ju dd’s apa rtm ent . A s M r. K leinm an\nco ncl uded , “O gd en won.”\nM r. Ju dd r ef used t o h ir e m over s fo r h is boyfr iend ’s bel ong ing s, ins isting o n per sona lly\npa cking a nd t a k ing a n inv ent ory o f ev ery it em in his boyfr iend ’s pl ace. W hat sh ou ld h ave\nta k en 2 d ays to ok 1 week . O nce th e item s wer e tr a nspo rted t o M r. Ju dd’s apa rtm ent , M r.\nK leinm an beg an to co mplain ab ou t M r. Ju dd’s “cr azy r u les” ab ou t wh ere item s co uld b e\npl aced o n th e booksh elf, wh ich d ir ect ion th e hang ers in th e cl oset f a ced , a nd wh ether t h eir\ncl oth es could b e int erming led . M oreo ver , M r. K leinm an co mplaine d t h at t h er e wa s hard ly\na ny spa ce fo r h is po ssessio ns beca use Mr. Ju dd nev er t h rew any th ing a wa y. “I ’m t er rif ied o f\nlo sing so mething im porta nt ,” ad ded M r. Ju dd.\nO ver t h e ensu ing week s, a rg u m ent s bro ke ou t nig htly a s th ey u npa cked b oxes and set tled\nin. M ak ing m atter s wo rse, M r. Ju dd wo uld o ft en come hom e aft er 9 :0 0 o r 10 :00 p. m .,\nb eca use he had a per sona l r u le to a lwa ys have a b la nk “t o-d o” list b y t h e end o f t h e day. M r.\nK leinm an wo uld o ft en wake ea rly in th e m orning t o f ind M r. Ju dd g rim ly o rg aniz ing\nshelves or cl oset s or so rting b ooks alph ab et ica ll y b y a u th or. T hro u gh ou t t h is pr ocess, M r.\nJu dd a ppea red t o b e wo rk ing h ard a t ev eryth ing wh ile enj oying h im sel f l ess and g et ting l ess\nd one. M r. K leinm an fo u nd h im self f eel ing incr easing ly d et ach ed f r o m h is boyfr iend t h e\nlo ng er t h ey l iv ed t o get her .\nM r. Ju dd d enied sy mpt om s of d epr essio n and f r ee- flo ating a nx iet y. H e sa id t h at h e had\nnev er ex per iment ed wit h cig aret tes or a lco hol, a d ding , “I wo uld n’ t wa nt t o f eel l ik e I wa s\nou t o f co ntro l.” H e denied a f a m ily h ist ory o f m ent al il lness. H e wa s ra ised in a t wo -pa rent\nh ou seh old a nd wa s an ab ove aver ag e hig h sch ool a nd co lleg e st udent . H e wa s an onl y ch ild\nand f ir st sh ared a r o om a s a co lleg e fr esh man. H e descr ibed t h at ex per ience as being\nd if ficu lt d u e to “co nflict ing st yles—h e wa s a m ess and I k new th at t h ing s sh ou ld b e kept\nnea t.” H e had m oved m id-y ea r in to a sing le dorm r o om a nd h ad no t l iv ed wit h a ny one unt il\nMr. K leinm an m oved in. M r. Ju dd wa s wel l l ik ed b y h is boss, ea rning r eco gnit ion as\n“em ployee of t h e m ont h” th ree tim es in 2 y ea rs. F eed back f r o m co llea gu es and\nsu bord ina tes wa s less enthusia stic, ind icating t h at h e wa s over ly r ig id , per fect ionist ic, a nd\ncr itica l.\nO n ex am ina tio n, M r. Ju dd wa s a t h in man wit h ey eg la sses and g el led h air , sit ting o n a\nco uch nex t t o h is boyfr iend . H e wa s m eticu lo u sl y d ressed . H e wa s co oper ativ e wit h t h e 8/14/2019 Psychiatry Online | DSM Library\ninterview and sa t q u iet ly wh ile his boyfr iend spo ke, int erru pt ing o n a f ew occa sions to\nco ntra d ict . H is speech wa s no rm al in ra te and t o ne. H is aff ect wa s ir rit ab le. T her e wa s no\nev idence of d epr essio n. H e denied specif ic ph ob ia s and d id no t t h ink h e had ev er\nex per ienced a pa nic atta ck . A t t h e end o f t h e co nsu lt a tio n, M r. Ju dd r em ark ed , “I k no w I’m\nd if ficu lt , b u t I r ea lly d o wa nt t h is to wo rk o u t.”\nCo upl es tr ea tm ent wo uld pr ob ab ly f o cu s on th e rel atio nsh ip ra th er t h an on eit her o f t h e\ntwo m en, b u t t h e ca se repo rt cl ea rly f o cu ses on M r. Ju dd’s co ntrib utio n to t h e dif ficu lt ies in\nth e rel atio nsh ip. M r. Ju dd is viewed a s a co ntro ll ing , per fect ion- driv en, a nd inf lex ible\n“wo rk ah olic. ” H e hold s on to b el ong ing s ex cessiv ely a nd f ind s it d if ficu lt t o int egra te new\nitem s int o h is apa rtm ent , spend ing h ou rs sing le- hand edly o rg aniz ing b ooks th at co uld\no th er wise ju st b e pl aced o n a b ooksh elf. H e is driv en and u na ble to d el eg ate, a nd a lt h ou gh\nth ose qu alit ies can be ad apt ive in some cir cumstances, t h ey a re ca using h im d ist ress and\nd ysf unct ion in reg ard t o h is sit uatio n wit h h is boyfr iend a nd wit h h is co llea gu es at wo rk .\nM r. Ju dd a ppea rs to f u lf il l cr iter ia, t h er efore, f o r a D SM -5 d ia gno sis of o b sessiv e-\ncompu lsiv e per sona lit y d iso rd er ( O CP D).\nO CP D a nd o b sessiv e-co mpu lsiv e diso rd er ( O CD ) ca n be co morb id , b u t t h e two co nd itio ns\nusu ally ex ist sepa ra tel y. T he im porta nt d ist ing uish ing f a ct or is th at wh erea s O CP D is\nco nsid ered a m ala d apt ive pa tter n of b eh avio r m ark ed b y ex cessiv e co ntro l a nd inf lex ibilit y,\nO CD is ch ara ct er ized b y t h e pr esence of t r u e ob sessio ns and co mpu lsio ns.\nTher e ca n, h owev er, b e sig nifica nt b eh avio ra l o ver la p bet ween OCD a nd O CP D. F or\nex am ple, h oard ing b eh avio rs ca n b e co mmon to b oth d ia gno ses. I n OCP D, t h e ca use of t h e\nhoard ing d iso rd er is th e need f o r o rd er a nd co mpleteness, a nd M r. Ju dd r epo rts th at h e is\n“t er rif ied o f l o sing so mething im porta nt .” To co mpensa te fo r t h e fa ct t h at h is apa rtm ent is\nno w sh ared wit h h is boyfr iend —and is over fu ll—M r. Ju dd wo rk s grim ly int o t h e nig ht so\nt h at h is booksh elves and cl oset m aint ain th eir u su al st and ard o f ex cessiv e org aniz atio n. I n\nO CD , t h e ca use of t h e hoard ing t end s to b e eit her t h e avo id ance of o ner ou s co mpu lsiv e\nrit uals or o b sessio nal a nd o ft en irra tio na l f ea rs of inco mpleteness, h arm , a nd\nco ntam ina tio n. T he beh avio rs are ty pica ll y u nwa nted a nd d ist ressi ng, a nd a re lik ely t o l ea d 8/14/2019 Psychiatry Online | DSM Library\nto t h e accu mula tio n of o d d d eb ris su ch a s fing erna il cl ipping s or r o tten fo od . I n hoard ing\ndiso rd er , a new dia gno sis in DSM -5 , t h e fo cu s is ex clusiv ely o n a p er sist ent d if ficu lt y\nd isca rd ing o r pa rting wit h po ssessio ns ra th er t h an on a need f o r o rd er o r o n ob sessio ns and\nco mpu lsio ns.\nIn reg ard t o M r. Ju dd, it wo uld b e u sef ul t o specif icall y ex plore wh ether h is hoard ing\nbeh avio r a ttenu ates a specif ic, pa rticu la rly d ist ressing o r int ru siv e th ou gh t, a nd t o\nu nd erstand t h e ex tent o f h is accu mula tio ns. H is list -m ak ing a nd a rr a ng ing m ay b e\nco mpu lsio ns and m eet cr iter ia f o r O CD if t h ey a re fo u nd no t o nl y t o b e acco mpa nied b y\ntensio n and d if ficu lt y r el ax ing b u t a lso t o b e tim e-co nsu ming , d ist ressing , o ver ly r epet itiv e,\nand r it ualist ic. A lt h ou gh D SM -5 e nco ura g es an effo rt t o d ist ing uish b et ween OCP D, O CD ,\nand h oard ing d iso rd er , t h ese th re e diso rd er s ca n be co morb id wit h ea ch o th er .\nAs discu ssed in th e int ro d u ct io n to t h is ch apt er, S ect ion III o f D SM -5 o u tlines an\nalt er na tiv e m od el t h at incl udes fiv e per sona lit y d iso rd er t r a it d om ains (see Tab le 18 – in th e\nint ro d u ct io n to t h is ch apt er): neg ativ e aff ect ivity, d et ach ment , a nt ag o nism , d isinh ibitio n\n(v s. co nscient iousness) , a nd psy choticism . S ev eral o f t h ese fa ct ors are per tinent t o a\nd ia gno sis of O CP D. F or ex am ple, M r. Ju dd’s int erper sona l st yle wit h b oth h is boyfr iend\na nd h is co wo rk er s appea rs to b e m ark ed b y r ig id d et ach ment a nd r est rict ed l ev els of\nint imacy . H e m anif est s sig nifica nt a m ou nt s of neg ativ e affect ivity, a s ref lect ed in his grim\nper sist ence in continu ing t a sk s pa st t h e po int o f u sef ulness. F ina ll y , M r. Ju dd’s\nco mpu lsiv ity per va d es th e ent ire st ory , a s m ark ed b y ex tr em e co ns cient iousness and r ig id\nper fect ionism .\nH ays P : D et er mina tio n of t h e ob sessio nal per sona lit y . A m J Psy ch iatr y 12 9 (2): 2 17 – 219 ,\n19 72 P ubM ed I D : 50 410 64\nL och ner C , S er eb ro P , v a n der M erwe L , et a l: Co morb id o b sessiv e-co mpu lsiv e per sona lit y\ndiso rd er in ob sessiv e-co mpu lsiv e d iso rd er ( O CD ) : a m ark er o f sev erity . P ro g\nN eu ro psy choph arm aco l B io l P sy ch iatr y 35 (4): 10 87 – 10 92 , 2 0 11 PubM ed I D : 2 14 110 45\nP int o MA , E isen J, M anceb o M , et a l: O bsessiv e-co mpu lsiv e per sona lit y d iso rd er , in\nO bsessiv e-Co mpu lsiv e D iso rd er : S u bty pes and S pect ru m Co nditio ns . E dit ed b y 8/14/2019 Psychiatry Online | DSM Library\nAbra m owit z J, M cK ay D , T aylo r S. O xfo rd , U K , O xfo rd U niv ersit y P ress , 2 0 08 , pp 2 4 6 –\n© 2019 American Psychiatric Association\nhttps://graduateassignmenthelp.com/wp-content/uploads/2019/09/Logo-39.png 0 0 admin https://graduateassignmenthelp.com/wp-content/uploads/2019/09/Logo-39.png admin2019-09-21 06:23:172019-09-21 06:23:21you will take on the role of a psychology intern at a mental health facility working under the supervision of a licensed psychologist. I\nIdentify the key theorists associated with each approach. For this Assignment, you will write an essay that describes how you would apply...